focus group interviews qualitative research

Chapter 12. Focus Groups

Introduction.

Focus groups are a particular and special form of interviewing in which the interview asks focused questions of a group of persons, optimally between five and eight. This group can be close friends, family members, or complete strangers. They can have a lot in common or nothing in common. Unlike one-on-one interviews, which can probe deeply, focus group questions are narrowly tailored (“focused”) to a particular topic and issue and, with notable exceptions, operate at the shallow end of inquiry. For example, market researchers use focus groups to find out why groups of people choose one brand of product over another. Because focus groups are often used for commercial purposes, they sometimes have a bit of a stigma among researchers. This is unfortunate, as the focus group is a helpful addition to the qualitative researcher’s toolkit. Focus groups explicitly use group interaction to assist in the data collection. They are particularly useful as supplements to one-on-one interviews or in data triangulation. They are sometimes used to initiate areas of inquiry for later data collection methods. This chapter describes the main forms of focus groups, lays out some key differences among those forms, and provides guidance on how to manage focus group interviews.

Focus Groups: What Are They and When to Use Them

As interviews, focus groups can be helpfully distinguished from one-on-one interviews. The purpose of conducting a focus group is not to expand the number of people one interviews: the focus group is a different entity entirely. The focus is on the group and its interactions and evaluations rather than on the individuals in that group. If you want to know how individuals understand their lives and their individual experiences, it is best to ask them individually. If you want to find out how a group forms a collective opinion about something (whether a product or an event or an experience), then conducting a focus group is preferable. The power of focus groups resides in their being both focused and oriented to the group . They are best used when you are interested in the shared meanings of a group or how people discuss a topic publicly or when you want to observe the social formation of evaluations. The interaction of the group members is an asset in this method of data collection. If your questions would not benefit from group interaction, this is a good indicator that you should probably use individual interviews (chapter 11). Avoid using focus groups when you are interested in personal information or strive to uncover deeply buried beliefs or personal narratives. In general, you want to avoid using focus groups when the subject matter is polarizing, as people are less likely to be honest in a group setting. There are a few exceptions, such as when you are conducting focus groups with people who are not strangers and/or you are attempting to probe deeply into group beliefs and evaluations. But caution is warranted in these cases. [1]

As with interviewing in general, there are many forms of focus groups. Focus groups are widely used by nonresearchers, so it is important to distinguish these uses from the research focus group. Businesses routinely employ marketing focus groups to test out products or campaigns. Jury consultants employ “mock” jury focus groups, testing out legal case strategies in advance of actual trials. Organizations of various kinds use focus group interviews for program evaluation (e.g., to gauge the effectiveness of a diversity training workshop). The research focus group has many similarities with all these uses but is specifically tailored to a research (rather than applied) interest. The line between application and research use can be blurry, however. To take the case of evaluating the effectiveness of a diversity training workshop, the same interviewer may be conducting focus group interviews both to provide specific actionable feedback for the workshop leaders (this is the application aspect) and to learn more about how people respond to diversity training (an interesting research question with theoretically generalizable results).

When forming a focus group, there are two different strategies for inclusion. Diversity focus groups include people with diverse perspectives and experiences. This helps the researcher identify commonalities across this diversity and/or note interactions across differences. What kind of diversity to capture depends on the research question, but care should be taken to ensure that those participating are not set up for attack from other participants. This is why many warn against diversity focus groups, especially around politically sensitive topics. The other strategy is to build a convergence focus group , which includes people with similar perspectives and experiences. These are particularly helpful for identifying shared patterns and group consensus. The important thing is to closely consider who will be invited to participate and what the composition of the group will be in advance. Some review of sampling techniques (see chapter 5) may be helpful here.

Moderating a focus group can be a challenge (more on this below). For this reason, confining your group to no more than eight participants is recommended. You probably want at least four persons to capture group interaction. Fewer than four participants can also make it more difficult for participants to remain (relatively) anonymous—there is less of a group in which to hide. There are exceptions to these recommendations. You might want to conduct a focus group with a naturally occurring group, as in the case of a family of three, a social club of ten, or a program of fifteen. When the persons know one another, the problems of too few for anonymity don’t apply, and although ten to fifteen can be unwieldy to manage, there are strategies to make this possible. If you really are interested in this group’s dynamic (not just a set of random strangers’ dynamic), then you will want to include all its members or as many as are willing and able to participate.

There are many benefits to conducting focus groups, the first of which is their interactivity. Participants can make comparisons, can elaborate on what has been voiced by another, and can even check one another, leading to real-time reevaluations. This last benefit is one reason they are sometimes employed specifically for consciousness raising or building group cohesion. This form of data collection has an activist application when done carefully and appropriately. It can be fun, especially for the participants. Additionally, what does not come up in a focus group, especially when expected by the researcher, can be very illuminating.

Many of these benefits do incur costs, however. The multiplicity of voices in a good focus group interview can be overwhelming both to moderate and later to transcribe. Because of the focused nature, deep probing is not possible (or desirable). You might only get superficial thinking or what people are willing to put out there publicly. If that is what you are interested in, good. If you want deeper insight, you probably will not get that here. Relatedly, extreme views are often suppressed, and marginal viewpoints are unspoken or, if spoken, derided. You will get the majority group consensus and very little of minority viewpoints. Because people will be engaged with one another, there is the possibility of cut-off sentences, making it even more likely to hear broad brush themes and not detailed specifics. There really is very little opportunity for specific follow-up questions to individuals. Reading over a transcript, you may be frustrated by avenues of inquiry that were foreclosed early.

Some people expect that conducting focus groups is an efficient form of data collection. After all, you get to hear from eight people instead of just one in the same amount of time! But this is a serious misunderstanding. What you hear in a focus group is one single group interview or discussion. It is not the same thing at all as conducting eight single one-hour interviews. Each focus group counts as “one.” Most likely, you will need to conduct several focus groups, and you can design these as comparisons to one another. For example, the American Sociological Association (ASA) Task Force on First-Generation and Working-Class Persons in Sociology began its study of the impact of class in sociology by conducting five separate focus groups with different groups of sociologists: graduate students, faculty (in general), community college faculty, faculty of color, and a racially diverse group of students and faculty. Even though the total number of participants was close to forty, the “number” of cases was five. It is highly recommended that when employing focus groups, you plan on composing more than one and at least three. This allows you to take note of and potentially discount findings from a group with idiosyncratic dynamics, such as where a particularly dominant personality silences all other voices. In other words, putting all your eggs into a single focus group basket is not a good idea.

How to Conduct a Focus Group Interview/Discussion

Advance preparations.

Once you have selected your focus groups and set a date and time, there are a few things you will want to plan out before meeting.

As with interviews, you begin by creating an interview (or discussion) guide. Where a good one-on-one interview guide should include ten to twelve main topics with possible prompts and follow-ups (see the example provided in chapter 11), the focus group guide should be more narrowly tailored to a single focus or topic area. For example, a focus might be “How students coped with online learning during the pandemic,” and a series of possible questions would be drafted that would help prod participants to think about and discuss this topic. These questions or discussion prompts can be creative and may include stimulus materials (watching a video or hearing a story) or posing hypotheticals. For example, Cech ( 2021 ) has a great hypothetical, asking what a fictional character should do: keep his boring job in computers or follow his passion and open a restaurant. You can ask a focus group this question and see what results—how the group comes to define a “good job,” what questions they ask about the hypothetical (How boring is his job really? Does he hate getting up in the morning, or is it more of an everyday tedium? What kind of financial support will he have if he quits? Does he even know how to run a restaurant?), and how they reach a consensus or create clear patterns of disagreement are all interesting findings that can be generated through this technique.

As with the above example (“What should Joe do?”), it is best to keep the questions you ask simple and easily understood by everyone. Thinking about the sequence of the questions/prompts is important, just as it is in conducting any interviews.

Avoid embarrassing questions. Always leave an out for the “I have a friend who X” response rather than pushing people to divulge personal information. Asking “How do you think students coped?” is better than “How did you cope?” Chances are, some participants will begin talking about themselves without you directly asking them to do so, but allowing impersonal responses here is good. The group itself will determine how deep and how personal it wants to go. This is not the time or place to push anyone out of their comfort zone!

Of course, people have different levels of comfort talking publicly about certain topics. You will have provided detailed information to your focus group participants beforehand and secured consent. But even so, the conversation may take a turn that makes someone uncomfortable. Be on the lookout for this, and remind everyone of their ability to opt out—to stay silent or to leave if necessary. Rather than call attention to anyone in this way, you also want to let everyone know they are free to walk around—to get up and get coffee (more on this below) or use the restroom or just step out of the room to take a call. Of course, you don’t really want anyone to do any of these things, and chances are everyone will stay seated during the hour, but you should leave this “out” for those who need it.

Have copies of consent forms and any supplemental questionnaire (e.g., demographic information) you are using prepared in advance. Ask a friend or colleague to assist you on the day of the focus group. They can be responsible for making sure the recording equipment is functioning and may even take some notes on body language while you are moderating the discussion. Order food (coffee or snacks) for the group. This is important! Having refreshments will be appreciated by your participants and really damps down the anxiety level. Bring name tags and pens. Find a quiet welcoming space to convene. Often this is a classroom where you move chairs into a circle, but public libraries often have meeting rooms that are ideal places for community members to meet. Be sure that the space allows for food.

Researcher Note

When I was designing my research plan for studying activist groups, I consulted one of the best qualitative researchers I knew, my late friend Raphael Ezekiel, author of The Racist Mind . He looked at my plan to hand people demographic surveys at the end of the meetings I planned to observe and said, “This methodology is missing one crucial thing.” “What?” I asked breathlessly, anticipating some technical insider tip. “Chocolate!” he answered. “They’ll be tired, ready to leave when you ask them to fill something out. Offer an incentive, and they will stick around.” It worked! As the meetings began to wind down, I would whip some bags of chocolate candies out of my bag. Everyone would stare, and I’d say they were my thank-you gift to anyone who filled out my survey. Once I learned to include some sugar-free candies for diabetics, my typical response rate was 100 percent. (And it gave me an additional class-culture data point by noticing who chose which brand; sure enough, Lindt balls went faster at majority professional-middle-class groups, and Hershey’s minibars went faster at majority working-class groups.)

—Betsy Leondar-Wright, author of Missing Class , coauthor of The Color of Wealth , associate professor of sociology at Lasell University, and coordinator of staffing at the Mission Project for Class Action

During the Focus Group

As people arrive, greet them warmly, and make sure you get a signed consent form (if not in advance). If you are using name tags, ask them to fill one out and wear it. Let them get food and find a seat and do a little chatting, as they might wish. Once seated, many focus group moderators begin with a relevant icebreaker. This could be simple introductions that have some meaning or connection to the focus. In the case of the ASA task force focus groups discussed above, we asked people to introduce themselves and where they were working/studying (“Hi, I’m Allison, and I am a professor at Oregon State University”). You will also want to introduce yourself and the study in simple terms. They’ve already read the consent form, but you would be surprised at how many people ignore the details there or don’t remember them. Briefly talking about the study and then letting people ask any follow-up questions lays a good foundation for a successful discussion, as it reminds everyone what the point of the event is.

Focus groups should convene for between forty-five and ninety minutes. Of course, you must tell the participants the time you have chosen in advance, and you must promptly end at the time allotted. Do not make anyone nervous by extending the time. Let them know at the outset that you will adhere to this timeline. This should reduce the nervous checking of phones and watches and wall clocks as the end time draws near.

Set ground rules and expectations for the group discussion. My preference is to begin with a general question and let whoever wants to answer it do so, but other moderators expect each person to answer most questions. Explain how much cross-talk you will permit (or encourage). Again, my preference is to allow the group to pick up the ball and run with it, so I will sometimes keep my head purposefully down so that they engage with one another rather than me, but I have seen other moderators take a much more engaged position. Just be clear at the outset about what your expectations are. You may or may not want to explain how the group should deal with those who would dominate the conversation. Sometimes, simply stating at the outset that all voices should be heard is enough to create a more egalitarian discourse. Other times, you will have to actively step in to manage (moderate) the exchange to allow more voices to be heard. Finally, let people know they are free to get up to get more coffee or leave the room as they need (if you are OK with this). You may ask people to refrain from using their phones during the duration of the discussion. That is up to you too.

Either before or after the introductions (your call), begin recording the discussion with their collective permission and knowledge . If you have brought a friend or colleague to assist you (as you should), have them attend to the recording. Explain the role of your colleague to the group (e.g., they will monitor the recording and will take short notes throughout to help you when you read the transcript later; they will be a silent observer).

Once the focus group gets going, it may be difficult to keep up. You will need to make a lot of quick decisions during the discussion about whether to intervene or let it go unguided. Only you really care about the research question or topic, so only you will really know when the discussion is truly off topic. However you handle this, keep your “participation” to a minimum. According to Lune and Berg ( 2018:95 ), the moderator’s voice should show up in the transcript no more than 10 percent of the time. By the way, you should also ask your research assistant to take special note of the “intensity” of the conversation, as this may be lost in a transcript. If there are people looking overly excited or tapping their feet with impatience or nodding their heads in unison, you want some record of this for future analysis.

I’m not sure why this stuck with me, but I thought it would be interesting to share. When I was reviewing my plan for conducting focus groups with one of my committee members, he suggested that I give the participants their gift cards first. The incentive for participating in the study was a gift card of their choice, and typical processes dictate that participants must complete the study in order to receive their gift card. However, my committee member (who is Native himself) suggested I give it at the beginning. As a qualitative researcher, you build trust with the people you engage with. You are asking them to share their stories with you, their intimate moments, their vulnerabilities, their time. Not to mention that Native people are familiar with being academia’s subjects of interest with little to no benefit to be returned to them. To show my appreciation, one of the things I could do was to give their gifts at the beginning, regardless of whether or not they completed participating.

—Susanna Y. Park, PhD, mixed-methods researcher in public health and author of “How Native Women Seek Support as Survivors of Intimate Partner Violence: A Mixed-Methods Study”

After the Focus Group

Your “data” will be either fieldnotes taken during the focus group or, more desirably, transcripts of the recorded exchange. If you do not have permission to record the focus group discussion, make sure you take very clear notes during the exchange and then spend a few hours afterward filling them in as much as possible, creating a rich memo to yourself about what you saw and heard and experienced, including any notes about body language and interactions. Ideally, however, you will have recorded the discussion. It is still a good idea to spend some time immediately after the conclusion of the discussion to write a memo to yourself with all the things that may not make it into the written record (e.g., body language and interactions). This is also a good time to journal about or create a memo with your initial researcher reactions to what you saw, noting anything of particular interest that you want to come back to later on (e.g., “It was interesting that no one thought Joe should quit his job, but in the other focus group, half of the group did. I wonder if this has something to do with the fact that all the participants were first-generation college students. I should pay attention to class background here.”).

Please thank each of your participants in a follow-up email or text. Let them know you appreciated their time and invite follow-up questions or comments.

One of the difficult things about focus group transcripts is keeping speakers distinct. Eventually, you are going to be using pseudonyms for any publication, but for now, you probably want to know who said what. You can assign speaker numbers (“Speaker 1,” “Speaker 2”) and connect those identifications with particular demographic information in a separate document. Remember to clearly separate actual identifications (as with consent forms) to prevent breaches of anonymity. If you cannot identify a speaker when transcribing, you can write, “Unidentified Speaker.” Once you have your transcript(s) and memos and fieldnotes, you can begin analyzing the data (chapters 18 and 19).

Advanced: Focus Groups on Sensitive Topics

Throughout this chapter, I have recommended against raising sensitive topics in focus group discussions. As an introvert myself, I find the idea of discussing personal topics in a group disturbing, and I tend to avoid conducting these kinds of focus groups. And yet I have actually participated in focus groups that do discuss personal information and consequently have been of great value to me as a participant (and researcher) because of this. There are even some researchers who believe this is the best use of focus groups ( de Oliveira 2011 ). For example, Jordan et al. ( 2007 ) argue that focus groups should be considered most useful for illuminating locally sanctioned ways of talking about sensitive issues. So although I do not recommend the beginning qualitative researcher dive into deep waters before they can swim, this section will provide some guidelines for conducting focus groups on sensitive topics. To my mind, these are a minimum set of guidelines to follow when dealing with sensitive topics.

First, be transparent about the place of sensitive topics in your focus group. If the whole point of your focus group is to discuss something sensitive, such as how women gain support after traumatic sexual assault events, make this abundantly clear in your consent form and recruiting materials. It is never appropriate to blindside participants with sensitive or threatening topics .

Second, create a confidentiality form (figure 12.2) for each participant to sign. These forms carry no legal weight, but they do create an expectation of confidentiality for group members.

In order to respect the privacy of all participants in [insert name of study here], all parties are asked to read and sign the statement below. If you have any reason not to sign, please discuss this with [insert your name], the researcher of this study, I, ________________________, agree to maintain the confidentiality of the information discussed by all participants and researchers during the focus group discussion.

Signature: _____________________________ Date: _____________________

Researcher’s Signature:___________________ Date:______________________

Figure 12.2 Confidentiality Agreement of Focus Group Participants

Third, provide abundant space for opting out of the discussion. Participants are, of course, always permitted to refrain from answering a question or to ask for the recording to be stopped. It is important that focus group members know they have these rights during the group discussion as well. And if you see a person who is looking uncomfortable or like they want to hide, you need to step in affirmatively and remind everyone of these rights.

Finally, if things go “off the rails,” permit yourself the ability to end the focus group. Debrief with each member as necessary.

Further Readings

Barbour, Rosaline. 2018. Doing Focus Groups . 2nd ed. Thousand Oaks, CA: SAGE. Written by a medical sociologist based in the UK, this is a good how-to guide for conducting focus groups.

Gibson, Faith. 2007. “Conducting Focus Groups with Children and Young People: Strategies for Success.” Journal of Research in Nursing 12(5):473–483. As the title suggests, this article discusses both methodological and practical concerns when conducting focus groups with children and young people and offers some tips and strategies for doing so effectively.

Hopkins, Peter E. 2007. “Thinking Critically and Creatively about Focus Groups.” Area 39(4):528–535. Written from the perspective of critical/human geography, Hopkins draws on examples from his own work conducting focus groups with Muslim men. Useful for thinking about positionality.

Jordan, Joanne, Una Lynch, Marianne Moutray, Marie-Therese O’Hagan, Jean Orr, Sandra Peake, and John Power. 2007. “Using Focus Groups to Research Sensitive Issues: Insights from Group Interviews on Nursing in the Northern Ireland ‘Troubles.’” International Journal of Qualitative Methods 6(4), 1–19. A great example of using focus groups productively around emotional or sensitive topics. The authors suggest that focus groups should be considered most useful for illuminating locally sanctioned ways of talking about sensitive issues.

Merton, Robert K., Marjorie Fiske, and Patricia L. Kendall. 1956. The Focused Interview: A Manual of Problems and Procedures . New York: Free Press. This is one of the first classic texts on conducting interviews, including an entire chapter devoted to the “group interview” (chapter 6).

Morgan, David L. 1986. “Focus Groups.” Annual Review of Sociology 22:129–152. An excellent sociological review of the use of focus groups, comparing and contrasting to both surveys and interviews, with some suggestions for improving their use and developing greater rigor when utilizing them.

de Oliveira, Dorca Lucia. 2011. “The Use of Focus Groups to Investigate Sensitive Topics: An Example Taken from Research on Adolescent Girls’ Perceptions about Sexual Risks.” Cien Saude Colet 16(7):3093–3102. Another example of discussing sensitive topics in focus groups. Here, the author explores using focus groups with teenage girls to discuss AIDS, risk, and sexuality as a matter of public health interest.

Peek, Lori, and Alice Fothergill. 2009. “Using Focus Groups: Lessons from Studying Daycare Centers, 9/11, and Hurricane Katrina.” Qualitative Research 9(1):31–59. An examination of the efficacy and value of focus groups by comparing three separate projects: a study of teachers, parents, and children at two urban daycare centers; a study of the responses of second-generation Muslim Americans to the events of September 11; and a collaborative project on the experiences of children and youth following Hurricane Katrina. Throughout, the authors stress the strength of focus groups with marginalized, stigmatized, or vulnerable individuals.

Wilson, Valerie. 1997. “Focus Groups: A Useful Qualitative Method for Educational Research?” British Educational Research Journal 23(2):209–224. A basic description of how focus groups work using an example from a study intended to inform initiatives in health education and promotion in Scotland.

• Note that I have included a few examples of conducting focus groups with sensitive issues in the “ Further Readings ” section and have included an “ Advanced: Focus Groups on Sensitive Topics ” section on this area. ↵

A focus group interview is an interview with a small group of people on a specific topic.  “The power of focus groups resides in their being focused” (Patton 2002:388).  These are sometimes framed as “discussions” rather than interviews, with a discussion “moderator.”  Alternatively, the focus group is “a form of data collection whereby the researcher convenes a small group of people having similar attributes, experiences, or ‘focus’ and leads the group in a nondirective manner.  The objective is to surface the perspectives of the people in the group with as minimal influence by the researcher as possible” (Yin 2016:336).  See also diversity focus group and convergence focus group.

A form of focus group construction in which people with diverse perspectives and experiences are chosen for inclusion.  This helps the researcher identify commonalities across this diversity and/or note interactions across differences.  Contrast with a convergence focus group

A form of focus group construction in which people with similar perspectives and experiences are included.  These are particularly helpful for identifying shared patterns and group consensus.  Contrast with a diversity focus group .

Introduction to Qualitative Research Methods Copyright © 2023 by Allison Hurst is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License , except where otherwise noted.

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Zooming into Focus Groups: Strategies for Qualitative Research in the Era of Social Distancing

Lekshmi santhosh.

1 Department of Medicine, University of California-San Francisco, San Francisco, California

Juan C. Rojas

2 Department of Medicine, University of Chicago, Chicago, Illinois

Patrick G. Lyons

3 Department of Medicine, School of Medicine, Washington University, St. Louis, Missouri; and

4 Healthcare Innovation Laboratory, BJC HealthCare, St. Louis, Missouri

Associated Data

Qualitative research methods are important and have become increasingly prominent in medical education and research. The reason is simple: many pressing questions in these fields require qualitative approaches to elicit nuanced insights and additional meaning beyond standard quantitative measurements in surveys or observatons. Among the most common qualitative data collection methods are structured or semistructured in-person interviews and focus groups, in which participants describe their experiences relevant to the research question at hand. In the era of physical and social distancing because of the novel coronavirus disease (COVID-19) pandemic, little guidance exists for strategies for conducting focus groups or semistructured interviews. Here we describe our experience with, and recommendations for, conducting remote focus groups and/or interviews in the era of social distancing. Specifically, we discuss best practice recommendations for researchers using video teleconferencing programs to continue qualitative research during the COVID-19 pandemic.

Qualitative research focuses on exploring individuals’ perspectives related to specific research questions, issues, or activities ( 1 ). Frequently, structured interviews or focus groups are tools employed for data collection for qualitative research. In-person interviews are ideal, although phone and digital alternatives may be considered ( 2 , 3 ). However, little guidance exists for strategies for conducting focus groups or semistructured interviews in the era of physical and social distancing with the coronavirus disease (COVID-19) pandemic. In this article, we describe some strategies for conducting focus groups or structured interviews with the use of video conferencing platforms ( Figure 1 ). Video conferencing may provide researchers and research participants with a convenient and safe alternative to in-person qualitative research, albeit with some important limitations and considerations.

Key strategies to ensure successful remote focus groups and interviews. IRB = institutional review board.

Throughout 2019, we collaborated on a series of stakeholder focus groups to explore clinician experiences with patient handoffs between the intensive care unit and the wards. These focus groups, conducted in-person at our respective academic medical centers, helped us delineate key strengths and “pain points” of our handoff processes and identify facilitators and barriers to the user-centered design and implementation of a new process ( 4 ). We had scheduled subsequent in-person focus groups for this iterative design and testing process to take place in Spring 2020. However, we were forced to recalibrate our plans based on the rapidly changing COVID-19 situation and the situations of our intended participants (internal medicine residents). This article provides some practical guidance and reflections based on our experiences conducting semistructured focus groups using a videoconference platform with internal medicine residents at three academic medical centers. We outline our recommendations by describing the process of these remote focus groups, from planning and recruitment to the execution and technical troubleshooting of the videoconference.

Setting the Stage

More than ever, healthcare professionals are overtaxed because of increased clinical responsibilities; new or altered clinical environments and workflows; and increased burdens of administrative, educational, and investigatory work conducted by phone, e-mail, and video conference ( 5 – 7 ). Because of the school and childcare facility closures, many healthcare professionals may be engaged in nonclinical work while simultaneously caring for their children or supervising remote learning ( 8 ). With this in mind, we recommend that researchers carefully consider the timing of planned focus groups or interviews to maximize participation and minimize the strain on potential participants. Whenever possible, researchers should seek input on optimal timing and duration from potential participants.

The flexibility of video conferencing may potentially allow researchers to recruit participants by eliminating transportation and transit time barriers and allows for increased flexibility to consider scheduling focus groups or interviews at nontraditional times to accommodate the participants’ schedules.

Overall, we recommend that focus groups are conducted over video rather than audio if unable to be done in-person. Audio-only experiences are inherently more challenging than remote video sessions; it is difficult to tell when participants are speaking but muted, to identify an individual speaker among many participants, and to interpret tone and body language. In addition, audio-only encounters often limit crosstalk, which can enhance the depth of responses. We acknowledge that video is less private than audio, but it may be more private than in-person (e.g., a participant may decline to enroll in an in-person interview or group around a sensitive topic if they do not wish to be seen physically entering or exiting a known research room). Consent must specify whether audio alone is being recorded, or whether video and audio are both recorded.

Most importantly, before recruitment and consent, researchers should identify which video teleconferencing platform (e.g., Zoom, Google Meet, or Microsoft Teams) is best suited for the project ( Table 1 ); because these platforms share many of the same capabilities (e.g., screencasting/sharing and audio recording), this decision may be based on institutional adoption or availability.

Overview of several common videoconferencing platforms

Definition of abbreviation : HIPAA = Health Insurance Portability and Accountability Act.

Recruitment and Consent

Although some local institutional review board (IRB) procedures may have changed in response to COVID-19, qualitative research projects with human participants still require IRB review for determination of exempt status or formal approval. Researchers should obtain IRB approval to record the audio from the focus group or structured interview if a recording is desired.

Recruitment is likely to be predominantly virtual, in the form of e-mail “blasts” describing the study and providing the information needed for informed consent. After completing recruitment and selecting a video conferencing platform for the proposed research, we recommend providing attendees a password-protected electronic invitation to ensure the privacy of the session. In addition, it is helpful when this invitation includes an attached electronic calendar “event,” which can allow potential participants to quickly cross reference their electronic calendars, which are increasingly full of virtual meetings. Gray and colleagues found that participants wanted to synchronize these invitations with their electronic calendars and preferred the interview be limited to 1 hour at most, to avoid fatigue and schedule disruption ( 9 ). Zoom and other similar platforms offer a straightforward option for participants to add the session to their personal electronic calendars automatically. We recommend this method of invitation to increase convenience for participants who are increasingly accustomed to daily schedules of virtual meetings.

As with in-person focus groups, there is likely to be a “U-shaped” relationship between the number of participants and the volume and depth of insights gained within a session; too few participants may prevent dialogue and limit progress toward thematic saturation or uncovering new insights, whereas too many participants will preclude opportunities for deeper follow-up and will limit the amount of time that any single participant may contribute. Most commonly available videoconference platforms permit audience sizes of 50 or more, which far exceeds the number of participants a typical focus group would contain.

Presession Technical Preparation

It is crucial that researchers familiarize themselves with the interface and options of their chosen videoconference platform, both to maximize the effectiveness of their session facilitation and to improve their ability to solve common technical difficulties that may arise. This preparation should take place on the computing device that the researcher intends to use for research sessions to ensure that video, audio volume, and internet speed are adequate to host a successful video conference meeting. We recommend recording a practice session to become familiar with recording logistics and file storage locations, and to ensure the device’s microphone records clearly enough for participants’ hearing and transcription. Beyond the opportunity to troubleshoot the virtual platform, this practice session may also serve the second purpose of familiarizing the facilitator with the discussion questions.

Of note, researchers should evaluate the adequacy of their devices’ storage capabilities, given the large file sizes required to record audio and video. Many universities provide network storage solutions to members of their academic community, which may help facilitate storing large files. Importantly, if the research participants are patients, any recorded data (i.e., audio, video, and transcripts) are considered protected health information. These data require additional privacy considerations, especially around storage and electronic transfer. Because commercial video chat platforms may host or store files on their servers, the research team should ensure, ahead of time, that any commercial video chat platform used for research meets both the Health Insurance Portability and Accountability Act and institutional standards for secure data storage.

After successful completion of the trial run as a host, we recommend contacting the study participants before the session to ensure that any technical questions or concerns are addressed.

Introducing the Session

Initializing a virtual meeting is, in many ways, similar to initializing an in-person meeting. Like physical meetings, attendees may “trickle in” late because of preceding scheduled events or technical difficulties. We recommend allowing 1–5 minutes at the session’s beginning to account for late arrivals and to address technical issues if any are apparent. Once individuals are in the meeting, the facilitator can “lock” the session so uninvited attendees do not “Zoom-bomb.” In addition, researchers can further protect their meeting by using a Waiting Room, if available. Videoconference waiting rooms are virtual staging areas, which prevents attendees from joining a meeting until permitted, either individually or in a group, to enter. The facilitator should introduce the focus group or structured interviews just as they would an in-person session, including assurances regarding confidentiality, an overview of the session’s objectives, and an explicit statement of the session’s ground rules. The facilitator should obtain permission to record the focus group or structured interview and provide attendees the opportunity to leave the meeting if they do not consent to the recording. Finally, we recommend that researchers consider using a visual cue on a shared slide to remind them to initiate recording before beginning the session’s questions. Ideally, having two individuals record the meeting helps ensure redundancy so that if one individual has recording issues, the copy is preserved.

Depending on the size of the focus group or structured interview, the facilitator may wish to describe, at the meeting’s beginning, how attendee opinions will be solicited. For example, focus group participants can “unmute” themselves to speak or use the “raise hand” function on the meeting service. We recommend discouraging the use of the “chat” function because chat box contents are not recorded unless explicitly read aloud. If attendees do type in the chat box during the session, we recommend that the facilitator read the chat box contents aloud to capture these insights in the recording and transcript. Last, consider asking attendees to share their video feeds so participants and leaders can view attendee facial expressions and identify visual cues when individuals are about to speak (or are speaking, but are inadvertently muted). However, we recognize that this recommendation could limit participation by attendees without video-capable devices and/or put undue stress or burden on attendees who may be simultaneously parenting or multitasking. Above all, researchers should encourage attendees to make choices that will maximize their comfort with the session, and thus, maximize their contributions to the discussion.

During the Session

In general, remote qualitative inquiry sessions should follow a structure similar to that of face-to-face sessions. The facilitator should use effective moderation techniques online just as they would in-person. We have found that having an additional research team member serve as a scribe and timekeeper is helpful, if available. This teammate could also serve as a backup host if the primary host has unresolvable technical issues. Facilitators guiding semistructured interviews should ask follow-up probing questions and avoid sharing their own opinion, asking closed or leading questions, and other missteps that contribute to bias.

Within these general guidelines, however, the research team should be cognizant of the ways in which remote interactions differ from a live discussion. For instance, participants may be either more (e.g., because of additional perceived anonymity) or less (e.g., because of multitasking) likely to interact on videoconference, which may require proactive facilitation (e.g., direction questions or probes to individual participants). Similarly, a proactive facilitator may wish to be particularly attentive for openings to ask probing or follow-up questions, as some data suggest that online qualitative inquiry provides less opportunity for probing and follow-up ( 10 ). Furthermore, microphone technology is likely to preclude the degree of crosstalk seen in many face-to-face focus groups, which could limit the depth and quality of dialogue elicited. This lack of crosstalk may inhibit the ability to develop social norms, which are often a key factor distinguishing focus groups from individual structured interviews. It is not known whether facilitator behaviors or factors like focus group size can modify these limitations, although certain characteristics of focus group questions (e.g., open-ended) appear to yield richer discussion and data ( 10 ). Finally, if an audio-only focus group is the only option, we suggest using a visual model (e.g., a map or list of participants) to remind the facilitator of focus group participants, so notes can be transcribed visually under each participant.

Researchers should consider the need to maintain the privacy and potential anonymity of all participants, as outlined in the project’s IRB protocol. This consideration should also include any potential protected health information if the participants are patients. If strict anonymity is required, avoid stating participants’ names during the recording. If deidentification during transcription or review is appropriate, using the names of participants may increase the connection between the facilitator and the respondent, allowing for greater psychological safety.

After the Session

Concluding a virtual interview or focus group is similar to concluding an in-person session of the same type. The researchers should thank participants for their time, particularly given the stressors of the pandemic. In addition, we recommend discussing criteria for possible follow-up discussions. After ending the recording, ensure the file is saved to a secure location. Use professional transcription software to transcribe the audio recording from the focus group. Analyze the data with the qualitative framework outlined in the study design stage.

Because qualitative analysis of remote interviews and focus groups is typically conducted on transcribed audio, the decision to use a video platform often has little impact on data analysis. However, in some situations, the recorded video may prove advantageous. For example, the inclusion of video might facilitate the differentiation of speakers or clarification of unclear words during transcription or transcript reviews. Similarly, video might provide context around pauses, hand gestures, or facial expressions. Whether remote sessions have the same Hawthorne-esque effect on participants (i.e., do they behave in a particular way because of their awareness of being observed) is unknown. For instance, it is possible that participants behave differently when observed on video as compared with an audio-only (e.g., telephone) experience, or as compared with an in person session. One implication of this possibility could involve the perceived acceptability of multitasking or split attention; not infrequently, video participants elect not to share their individual video feeds.

Common Pitfalls and Strategies for Success

Qualitative interviews and focus groups, regardless of the setting, are subject to certain pitfalls along with a project’s progression from research question to analysis and dissemination. For instance, suboptimal recruitment practices (e.g., lack of advertisement) may limit enrollment, whereas incomplete or rushed interview scripts may not elicit complete or nuanced insights from participants. For remote interviews or focus groups, distance and technology may present additional obstacles (or interact with known risks), which can threaten a project’s success ( Table 2 ). Overall, the virtual qualitative experience offers a tradeoff between participant availability and an increased number of potential distractions. Whether these potential threats to qualitative insight are worth access to participants who might be unable to attend face-to-face sessions is likely to vary across research questions and teams of investigators. In general, these pitfalls can be avoided or mitigated with careful preplanning, practice sessions, and deliberate attention to areas of risk.

Potential remote focus group pitfalls and related strategies for success

Definition of abbreviation s: IRB = institutional review board; HIPAA = Health Insurance Portability and Accountability Act.

Conclusions

We hope that these practical tips can help with conducting rigorous qualitative inquiry through remote focus groups or structured interviews in the era of physical and social distancing.

Supplementary Material

Supported by an APCCMPD, CHEST, and ATS Education Research Award (L.S.).

Author Contributions : Conception and design: P.G.L. Drafting of the article: L.S., J.C.R., and P.G.L. Critical revision of the article for important intellectual content: L.S., J.C.R., and P.G.L. Final approval of the article: L.S., J.C.R., and P.G.L. Administrative, technical, or logistic support: P.G.L.

Author disclosures are available with the text of this article at www.atsjournals.org .

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Chapter 14: Focus groups

Tess Tsindos

Learning Outcomes

Upon completion of this chapter, you should be able to:

• Assess when to use focus groups in qualitative research.
• Develop questions for a focus group guide.
• Understand how to conduct a focus group.

What are focus groups?

Focus groups are convened to discuss an issue of mutual concern. The purpose of a focus group is to explore the experiences, understandings, opinions or motivations of research participants. 1 While individual interviews explore the experiences of (usually) one participant (see Chapter 13 ), focus groups are conducted with three or more people who share an experience or concern. The conversation between participants in a focus group is mediated and facilitated by the researcher. Focus groups can be used when little is known about the participants or a topic (an exploratory process), when testing new ideas (e.g. acceptability of a program or intervention) or when undertaking an evaluation of a service or product.

The focus of the discussion is on the interaction between participants in the group; some participants may have similar experiences or views, while others have different experiences. The group dynamic is important and therefore it is important that participants lead the discussion and are encouraged to talk through their similarities and differences, so that the researcher might gain a well-rounded perspective and account of the topic. A group might be homogeneous, get along well and share similar experiences. Or the group might be heterogeneous and have differing opinions and experiences. Participants might know each other because they have been recruited from the same program or community, or they could be total strangers. All these elements contribute to the focus of discussion, and to the group dynamic; that is, the interactivity of the focus group.

How many focus group members should there be?

Ideally, a focus group should include 6–10 participants 2 and the conversation should be moderated by the researcher, using a focus group discussion guide. However, the number of participants may vary according to the topic and the number of participants able to be recruited. The data collected from focus groups tends to differ from interview data because people respond and compare their own experiences with those of others in the group. Therefore, the number and composition of group members influence the data gathered.

Having too many people in a group means that discussion can become chaotic and it is unlikely that everyone in the group will have a say. Having too few people means that there may not be sufficient interaction to enable to capture a group perspective. Focus groups have been conducted with as few as two people: in a focus group conducted by one of the authors of this chapter, several participants had been invited, but only two attended. Since participants were difficult to recruit from the target population, it was not feasible to cancel the focus group. The topic was recovery after percutaneous coronary intervention (a cardiac procedure). The focus group discussion developed into an intimate conversation between two older men about their challenges in physical recovery and the psychological effects of not being able to fulfil a traditional male role. The small group size was serendipitous, in that the researcher may not have been able to collect such rich data had the group been larger. 3

The researcher (s)

It is common to have two researchers present in a focus group. One facilitates the group, while the other observes and records the session, and takes notes about who said what, body language and other observable information that contributes to the context of the data being collected. The observer should be as unobtrusive as possible and not participate in the group discussion. Similar to interviews, focus groups are audio-recorded so the conversation can be transcribed for analysis.  The researcher is encouraged to build rapport with focus group participants, which is aided by having a friendly and approachable manner. The focus group method enables the facilitator to probe ideas as they arise and to check their understanding of participants’ responses. This active facilitation enhances the robustness of the data collected. The quality of the data collected will depend greatly on how effective the researcher is at facilitating the group, and thus good interpersonal skills are essential. Conducting effective focus group discussions comes with practice and experience.

How long should a focus group be?

There are no strict rules about how long a focus group should be. Different groups will likely run for different amounts of time because this depends on the research question/s and the types of group members. For example, a group of people who know each other and have a common experience may need no longer than 45 minutes, whereas a group of strangers with different experiences may need up to 2 hours. Additionally, the number of people in the focus group will affect the amount of time needed. A focus group discussion with 6 participants may likely be shorter than a focus group with 12 participants.

Designing the focus group guide

Before the commencement of a focus group, the researchers need to develop a focus group discussion guide, which is similar to an interview guide. Both aim to explore the experiences, understandings, opinions and motivations of participants. If the study’s research methods include interviews and focus groups, the questions will be very similar. T he difference is that the focus group discussion guide do es not typically ask questions to elicit individual storytelling, but rather to ask questions to invite discussion of shared experiences , in which participants confirm or contrast each others ’ views . If focus groups are the sole data collection method, the researcher may consult existing literature, speak to experts, including people with lived experience about the focus of the research, and draw on their knowledge so that the topics and questions can be mapped to the research question/s.

The focus group guide should be developed well in advance of commencing data collection. This provides time for the facilitator and the observer to explore together the language and clarity of questions, the order and flow of the guide, and whether the instructions for participants are clear and comprehensive. To facilitate free-flowing responses, it is important to use open-ended questions that encourage participants to be expansive in their responses. Examples of open-ended question formats include those that start with ‘who’, ‘how’ ‘tell me more about’ and ‘where’.

Pilot interview/s enable the researchers to test the interview guide. However, they are often not conducted because it can be difficult to recruit enough relevant participants. Instead, focus group questions might be reviewed by other members of the research team for clarity and comprehensiveness. The study design will determine the number of questions asked and the extent of the focus group guide. The target population may also determine the extent of the focus group guide; for example, clinicians who are time-poor may need shorter focus groups while patient populations may be interested in exploring their experiences in detail and at length.

Following is a template that can be adapted for the introduction of a focus group. Table 14.1 offers example questions for a focus group discussion guide.

Focus group introduction

‘Hi everyone. My name is [insert name] and I’m from [insert organisation]. I am conducting [describe study]. Thank you for agreeing to be part of this focus group today. You were invited to participate in this focus group because [include reason]. Today we would like to discuss [outline topics]. We anticipate that the session will go for approximately [insert expected time]. Before we get started, I’d like to explain how we would like to structure the discussion. 1. We would like to hear from everyone present. This may mean that I will call on you by name to respond to a question. I may also indicate to you when it’s time to wrap up your thoughts so we can move on to another person or topic. 2. Feel free to respond directly to each other. I’m here to facilitate the discussion, but you are encouraged to respond to the other participants in this group. 3. We are recording the session today. This will ensure that we capture everything discussed. Your names will not be used in the reporting of this data and we will be using pseudonyms or codes instead when writing up results. 4. Please be respectful of what other participants share. Due to the nature of focus groups, we cannot ensure confidentiality, but we do ask that you do not repeat what is discussed in this group to people who were not present. You should feel free to not answer a question if you don’t feel comfortable answering. Do you have any questions before we begin?”

Table 14.1. Focus group guide: Example questions for a descriptive study

An earlier variation of this table has appeared in the Supplementary material for the article Why do students plagiarise? Informing higher education teaching and learning policy and practice . 4

Setting up the f ocus group

In the past, most focus groups were conducted in person. Emerging technologies have enabled the conduct of focus groups online, using teleconferencing and videoconferencing platforms. While it is more challenging to conduct a focus group online – primarily because participants’ body language is often not seen – it can be a very useful method of collecting data. The benefits include low cost, greater access to participants in different locations and time efficiencies. 5 Participants who are less inclined to participate verbally are able to use ‘chat’ functions to contribute their comments. Whether the focus group is face-to-face or online, the facilitator will need to help participants feel as comfortable as possible and encourage discussion.

Focus group activities

Focus groups may incorporate activities in addition to, or to aid discussion; for example, sorting and ranking activities to prioritise topics for discussion in the focus group; or a River of Life 6 activity (see Chapter 18 ).

C onsiderations for the conduct of focus groups

C onfidentiality should be addressed explicitly; for example, using the Chatham House rule, which sets out expectations about repeating what is said in a meeting without revealing the identities of who said it or other participants. 7  It is advisable to provide each participant with an explanatory statement to read, which states that confidentiality is essential to the focus group discussions.

Expectations need to be communicated in advance. Many of the tips for interviews in Chapter 13 apply also to focus groups, but it is important to communicate the researchers’ and the group’s expectations upfront. Some, but not all, of the expectations of focus groups are included in Table 14.2. The facilitator should explain these expectations before the focus group starts. Table 14.3 provides examples of studies using focus groups for data collection.

Table 14.2. Dos and don’ts of conducting focus groups

Power imbalances. When setting up a focus group, the facilitator should pay strict attention to how homogenous the group needs to be concerning the topic, and how possible power imbalances might affect the data collection. For example, if the research question seeks to understand why drug administration errors occur in hospitals, it would not be a good idea to have doctors, nurses and pharmacists in the same group. Why? Because they might not feel comfortable expressing views in front of the very people they have seen make errors. Instead, you could run three separate groups: one with doctors, one with nurses and another with pharmacists. Conducting separate group discussions helps to avoid the chance that a powerful group might dominate the discussion and enables each group member to express their views openly.

Participant identity. The facilitator should invite participants to introduce themselves to other group members, to encourage familiarity; name tags can help participants remember each other’s names. The researchers will need to maintain a list of participants and any necessary demographic details.

Risk. The possibility of distress or harm occurring must always be considered in a focus group. Participants may become distressed because sensitive topics are being discussed, and there is always a risk that some participants might overshare their experiences. The facilitator will need to judge when to stop the discussion if it becomes clear that one or more participants are distressed. 8 Researchers should have a clear protocol developed that provides advice about how to handle distress.

After the f ocus g roup

Once the discussion is concluded, participants should be thanked for their time and contributions. Explain how participants might contact the researcher if they have any questions or would like to provide the facilitator with follow-up information. If the focus group has covered sensitive topics or any participants have become distressed during the discussion, make sure that you spend some time privately with the participant to provide appropriate referrals and follow-up (see Section 6 ). Referrals and follow-up are usually described in the protocol addressing distress.

Data analysis is discussed in Section 4 , but it is important to know what to do immediately after each focus group is completed. Download (or upload) the recording from the audio-recording device to ensure it is saved in a secure location that can only be accessed by people on the research team (see Chapter 34). The recording should be transcribed; that is, reproduced verbatim, for data coding and analysis. The transcription of data is an important step in the analysis process, and it is important to note that this is a highly time-consuming task. Transcribing a 60-minute focus group discussion can take up to 10 hours.

Table 14.3. Examples of focus groups

Focus groups and (individual interviews) are the most common data collection techniques in qualitative research. The success of a focus group depends on the group composition and the effectiveness of the facilitator. It is important to formulate open-ended focus group questions that are understandable and easy for participants to engage with. Setting up the focus group discussion guide, rules and other considerations will enhance the experience of the focus group for the participant and the researchers, as well as the quality of the data collected.

• Gill P, Stewart K, Treasure E et al . Methods of data collection in qualitative research: interviews and focus groups. Br Dent J . 2008;204(6):291-295. doi:10.1038/bdj.2008.192
• Gill, P, Baillie, J. Interviews and focus groups in qualitative research: an update for the digital age. Br Dent J . 2018;225:668-672. doi:10.1038/sj.bdj.2018.815
• Soh S-E, Barker AL, Ayton DR et al. What matters most to patients following percutaneous coronary interventions? A new patient-reported outcome measure developed using Rasch analysis. PLoS ONE . 2019;14(9):e0222185. doi.org/10.1371/journal.pone.0222185
• Ayton D, Hillman C, Hatzikiriakidis K, et al. Why do students plagiarise? Informing higher education teaching and learning policy and practice. Stud High Educ . Sep 2 2022;47(9):1921-1934. doi:10.1080/03075079.2021.1985103
• Abrams K, Gaiser T. Online focus groups. In: Field N, Lee R, Blank G, eds. The Sage Handbook of Online Research Methods . Sage Publications, 2016;435–450.
• Moussa Z. Rivers of life. Participatory Learning and Action. Community-based adaptation to climate change, 2009. The International Institute for Environment and Development. Accessed March 24, 2023. https://www.iied.org/g02828
• The Chatham House rule. Chatham House, The Royal Institute of International Affairs, 2023. Accessed March 24, 2023. https://www.chathamhouse.org/about-us/chatham-house-rule#:~:text=The%20Rule%20reads%20as%20follows,other%20participant%2C%20may%20be%20revealed .
• Sim J, Waterfield J. Focus group methodology: some ethical challenges. Qual Quant. 2019;53:3003-3022. doi/10.1007/s11135-019-00914-5
• van der Spek N, Vos J, van Uden-Kraan CF et al. Meaning making in cancer survivors: a focus group study. P LoS ONE . 2013;8(9):e76089. doi.org/10.1371/journal.pone.0076089
• Visser E, Den Oudsten BL, Traa MJ et al . Patients’ experiences and wellbeing after injury: a focus group study. PLoS ONE . 2021;1 6(1):e0245198. doi.org/10.1371/journal.pone.0245198
• Moynihan R, Sims R, Hersch J et al . Communicating about overdiagnosis: learning from community focus groups on osteoporosis. PLoS ONE . 2017;12(2):e0170142. doi.org/10.1371/journal.pone.0170142
• Sabet Sarvestani A, Bufumbo L, Geiger JD et al. . Traditional male circumcision in Uganda: a qualitative focus group discussion analysis. PLoS ONE . 2012;7(10):e45316. doi.org/10.1371/journal.pone.0045316

Qualitative Research – a practical guide for health and social care researchers and practitioners Copyright © 2023 by Tess Tsindos is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License , except where otherwise noted.

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How to Interview and Conduct Focus Groups

Available formats, also available from.

• Table of contents
• Contributor bios
• Reviews and awards
• Book details

Interviews and focus groups are essential tools of qualitative research. This guide shows students and early-career researchers how to prepare for and conduct interviews and focus groups.

This book shows researchers how to plan for and conduct interviews and focus groups, and how to use them in various qualitative research designs. It also explains how to code, analyze, and report the data once it's been gathered.

By following the advice in this book, you will hone your inductive logic skills and learn how to convey the authentic voices of your interview subjects. In addition, you will learn professional skills for using technology ethically and appropriately.

Helpful tools in the book include example interview protocols, tips for recruitment and requesting consent, group facilitation guidelines, instructions for creating codebooks, and samples of different writing and publishing formats.

This book is part of APA's Concise Guides to Conducting Behavioral, Health, and Social Science Research series. Aimed at undergraduate students in research methods courses or others with a lab or research project, each book describes a key stage in the research process. Collectively, these books provide a solid grounding in research from start to finish.

Series Foreword Arthur M. Nezu Introduction

• Chapter 1: Qualitative Research Essentials
• Chapter 2: Interviews
• Chapter 3: Focus Groups
• Chapter 4: Combining Interviews and Focus Groups and Mixing Methods
• Chapter 5. Addressing Rigor, Validity, and Reliability
• Chapter 6: Transcribing and Coding
• Chapter 7. Analyzing Qualitative Data
• Chapter 8: Writing up and Publishing Results

Jen Katz-Buonincontro, PhD, MFA, is professor and associate dean of research in the School of Education at Drexel University in Philadelphia, PA. She also serves as president for the Society for the Psychology of Aesthetics, Creativity and the Arts (APA Division 10).

Helping children and adults learn to think and act in creative ways that optimizes their academic and professional success is the central motivation of her research, teaching and service. Her research aims to clarify and build sociocognitive theories of creative agency to ultimately advance educational research with knowledge and applied teaching tools.

With great sense of an experienced researcher and educator, Jen Katz-Buonincontro leads us through the “why” and “how” of qualitative research practices, from reflecting and deciding upon theoretical perspectives and research design, to the nuts-and-bolts of crafting interview protocols, coding, analyzing, and presenting rich qualitative data. Written with candor and in a conversational tone, the book emphasizes the role of reflexivity and positionality in building respectful relationship between researchers and interviewees, an ingredient ultimately leading to uncovering and telling delightful truths about people and their experiences. This comprehensive guide to interviewing and conducting focus groups, full of useful tips and resources, is a must-have for new and seasoned qualitative researchers alike. —Magdalena G. Grohman, PhD, Associate Director and Researcher at Center for Values in Medicine, Science, and Technology, The University of Texas at Dallas

I highly recommend How to Interview and Conduct Focus Groups to university instructors who are teaching interview methods and students who are learning them. Katz-Buonincontro describes key differences between one-on-one interviews and focus group interviews and provides detailed strategies for conducting interviews, transcribing them, and coding and analyzing interview data. She also explains the key roles of theory and researcher identity in the research process and how to prepare one’s qualitative results for publication. This will be a very useful guide for novice researchers! —Peter Youngs, PhD, Professor, Department of Curriculum, Instruction, and Special Education, University of Virginia, Charlottesville

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Qualitative Research: Introducing focus groups

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• a Glasgow University Media Group, Department of Sociology, University of Glasgow, Glasgow G12 8LF

This paper introduces focus group methodology, gives advice on group composition, running the groups, and analysing the results. Focus groups have advantages for researchers in the field of health and medicine: they do not discriminate against people who cannot read or write and they can encourage participation from people reluctant to be interviewed on their own or who feel they have nothing to say.

This is the fifth in a series of seven articles describing non-quantitative techniques and showing their value in health research

**FIGURE OMITTED**

Rationale and uses of focus groups

Focus groups are a form of group interview that capitalises on communication between research participants in order to generate data. Although group interviews are often used simply as a quick and convenient way to collect data from several people simultaneously, focus groups explicitly use group interaction as part of the method. This means that instead of the researcher asking each person to respond to a question in turn, people are encouraged to talk to one another: asking questions, exchanging anecdotes and commenting on each other's experiences and points of view. 1 The method is particularly useful for exploring people's knowledge and experiences and can be used to examine not only what people think but how they think and why they think that way.

Focus groups were originally used within communication studies to explore the effects of films and television programmes, 2 and are a popular method for assessing health education messages and examining public understandings of illness and of health behaviours. 3 4 5 6 7 They are widely used to examine people's experiences of disease and of health services. 8 9 and are an effective technique for exploring the attitudes and needs of staff. 10 11

The idea behind the focus group method is that group processes can help people to explore and …

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• Published: 22 March 2008

Methods of data collection in qualitative research: interviews and focus groups

• P. Gill 1 ,
• K. Stewart 2 ,
• E. Treasure 3 &
• B. Chadwick 4  

British Dental Journal volume  204 ,  pages 291–295 ( 2008 ) Cite this article

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Interviews and focus groups are the most common methods of data collection used in qualitative healthcare research

Interviews can be used to explore the views, experiences, beliefs and motivations of individual participants

Focus group use group dynamics to generate qualitative data

Qualitative research in dentistry

Conducting qualitative interviews with school children in dental research

Analysing and presenting qualitative data

This paper explores the most common methods of data collection used in qualitative research: interviews and focus groups. The paper examines each method in detail, focusing on how they work in practice, when their use is appropriate and what they can offer dentistry. Examples of empirical studies that have used interviews or focus groups are also provided.

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Interviews in the social sciences

A review of technical and quality assessment considerations of audio-visual and web-conferencing focus groups in qualitative health research

Professionalism in dentistry: deconstructing common terminology, introduction.

Having explored the nature and purpose of qualitative research in the previous paper, this paper explores methods of data collection used in qualitative research. There are a variety of methods of data collection in qualitative research, including observations, textual or visual analysis (eg from books or videos) and interviews (individual or group). 1 However, the most common methods used, particularly in healthcare research, are interviews and focus groups. 2 , 3

The purpose of this paper is to explore these two methods in more detail, in particular how they work in practice, the purpose of each, when their use is appropriate and what they can offer dental research.

Qualitative research interviews

There are three fundamental types of research interviews: structured, semi-structured and unstructured. Structured interviews are, essentially, verbally administered questionnaires, in which a list of predetermined questions are asked, with little or no variation and with no scope for follow-up questions to responses that warrant further elaboration. Consequently, they are relatively quick and easy to administer and may be of particular use if clarification of certain questions are required or if there are likely to be literacy or numeracy problems with the respondents. However, by their very nature, they only allow for limited participant responses and are, therefore, of little use if 'depth' is required.

Conversely, unstructured interviews do not reflect any preconceived theories or ideas and are performed with little or no organisation. 4 Such an interview may simply start with an opening question such as 'Can you tell me about your experience of visiting the dentist?' and will then progress based, primarily, upon the initial response. Unstructured interviews are usually very time-consuming (often lasting several hours) and can be difficult to manage, and to participate in, as the lack of predetermined interview questions provides little guidance on what to talk about (which many participants find confusing and unhelpful). Their use is, therefore, generally only considered where significant 'depth' is required, or where virtually nothing is known about the subject area (or a different perspective of a known subject area is required).

Semi-structured interviews consist of several key questions that help to define the areas to be explored, but also allows the interviewer or interviewee to diverge in order to pursue an idea or response in more detail. 2 This interview format is used most frequently in healthcare, as it provides participants with some guidance on what to talk about, which many find helpful. The flexibility of this approach, particularly compared to structured interviews, also allows for the discovery or elaboration of information that is important to participants but may not have previously been thought of as pertinent by the research team.

For example, in a recent dental public heath study, 5 school children in Cardiff, UK were interviewed about their food choices and preferences. A key finding that emerged from semi-structured interviews, which was not previously thought to be as highly influential as the data subsequently confirmed, was the significance of peer-pressure in influencing children's food choices and preferences. This finding was also established primarily through follow-up questioning (eg probing interesting responses with follow-up questions, such as 'Can you tell me a bit more about that?') and, therefore, may not have emerged in the same way, if at all, if asked as a predetermined question.

The purpose of research interviews

The purpose of the research interview is to explore the views, experiences, beliefs and/or motivations of individuals on specific matters (eg factors that influence their attendance at the dentist). Qualitative methods, such as interviews, are believed to provide a 'deeper' understanding of social phenomena than would be obtained from purely quantitative methods, such as questionnaires. 1 Interviews are, therefore, most appropriate where little is already known about the study phenomenon or where detailed insights are required from individual participants. They are also particularly appropriate for exploring sensitive topics, where participants may not want to talk about such issues in a group environment.

Examples of dental studies that have collected data using interviews are 'Examining the psychosocial process involved in regular dental attendance' 6 and 'Exploring factors governing dentists' treatment philosophies'. 7 Gibson et al . 6 provided an improved understanding of factors that influenced people's regular attendance with their dentist. The study by Kay and Blinkhorn 7 provided a detailed insight into factors that influenced GDPs' decision making in relation to treatment choices. The study found that dentists' clinical decisions about treatments were not necessarily related to pathology or treatment options, as was perhaps initially thought, but also involved discussions with patients, patients' values and dentists' feelings of self esteem and conscience.

There are many similarities between clinical encounters and research interviews, in that both employ similar interpersonal skills, such as questioning, conversing and listening. However, there are also some fundamental differences between the two, such as the purpose of the encounter, reasons for participating, roles of the people involved and how the interview is conducted and recorded. 8

The primary purpose of clinical encounters is for the dentist to ask the patient questions in order to acquire sufficient information to inform decision making and treatment options. However, the constraints of most consultations are such that any open-ended questioning needs to be brought to a conclusion within a fairly short time. 2 In contrast, the fundamental purpose of the research interview is to listen attentively to what respondents have to say, in order to acquire more knowledge about the study topic. 9 Unlike the clinical encounter, it is not to intentionally offer any form of help or advice, which many researchers have neither the training nor the time for. Research interviewing therefore requires a different approach and a different range of skills.

The interview

When designing an interview schedule it is imperative to ask questions that are likely to yield as much information about the study phenomenon as possible and also be able to address the aims and objectives of the research. In a qualitative interview, good questions should be open-ended (ie, require more than a yes/no answer), neutral, sensitive and understandable. 2 It is usually best to start with questions that participants can answer easily and then proceed to more difficult or sensitive topics. 2 This can help put respondents at ease, build up confidence and rapport and often generates rich data that subsequently develops the interview further.

As in any research, it is often wise to first pilot the interview schedule on several respondents prior to data collection proper. 8 This allows the research team to establish if the schedule is clear, understandable and capable of answering the research questions, and if, therefore, any changes to the interview schedule are required.

The length of interviews varies depending on the topic, researcher and participant. However, on average, healthcare interviews last 20-60 minutes. Interviews can be performed on a one-off or, if change over time is of interest, repeated basis, 4 for example exploring the psychosocial impact of oral trauma on participants and their subsequent experiences of cosmetic dental surgery.

Developing the interview

Before an interview takes place, respondents should be informed about the study details and given assurance about ethical principles, such as anonymity and confidentiality. 2 This gives respondents some idea of what to expect from the interview, increases the likelihood of honesty and is also a fundamental aspect of the informed consent process.

Wherever possible, interviews should be conducted in areas free from distractions and at times and locations that are most suitable for participants. For many this may be at their own home in the evenings. Whilst researchers may have less control over the home environment, familiarity may help the respondent to relax and result in a more productive interview. 9 Establishing rapport with participants prior to the interview is also important as this can also have a positive effect on the subsequent development of the interview.

When conducting the actual interview it is prudent for the interviewer to familiarise themselves with the interview schedule, so that the process appears more natural and less rehearsed. However, to ensure that the interview is as productive as possible, researchers must possess a repertoire of skills and techniques to ensure that comprehensive and representative data are collected during the interview. 10 One of the most important skills is the ability to listen attentively to what is being said, so that participants are able to recount their experiences as fully as possible, without unnecessary interruptions.

Other important skills include adopting open and emotionally neutral body language, nodding, smiling, looking interested and making encouraging noises (eg, 'Mmmm') during the interview. 2 The strategic use of silence, if used appropriately, can also be highly effective at getting respondents to contemplate their responses, talk more, elaborate or clarify particular issues. Other techniques that can be used to develop the interview further include reflecting on remarks made by participants (eg, 'Pain?') and probing remarks ('When you said you were afraid of going to the dentist what did you mean?'). 9 Where appropriate, it is also wise to seek clarification from respondents if it is unclear what they mean. The use of 'leading' or 'loaded' questions that may unduly influence responses should always be avoided (eg, 'So you think dental surgery waiting rooms are frightening?' rather than 'How do you find the waiting room at the dentists?').

At the end of the interview it is important to thank participants for their time and ask them if there is anything they would like to add. This gives respondents an opportunity to deal with issues that they have thought about, or think are important but have not been dealt with by the interviewer. 9 This can often lead to the discovery of new, unanticipated information. Respondents should also be debriefed about the study after the interview has finished.

All interviews should be tape recorded and transcribed verbatim afterwards, as this protects against bias and provides a permanent record of what was and was not said. 8 It is often also helpful to make 'field notes' during and immediately after each interview about observations, thoughts and ideas about the interview, as this can help in data analysis process. 4 , 8

Focus groups

Focus groups share many common features with less structured interviews, but there is more to them than merely collecting similar data from many participants at once. A focus group is a group discussion on a particular topic organised for research purposes. This discussion is guided, monitored and recorded by a researcher (sometimes called a moderator or facilitator). 11 , 12

Focus groups were first used as a research method in market research, originating in the 1940s in the work of the Bureau of Applied Social Research at Columbia University. Eventually the success of focus groups as a marketing tool in the private sector resulted in its use in public sector marketing, such as the assessment of the impact of health education campaigns. 13 However, focus group techniques, as used in public and private sectors, have diverged over time. Therefore, in this paper, we seek to describe focus groups as they are used in academic research.

When focus groups are used

Focus groups are used for generating information on collective views, and the meanings that lie behind those views. They are also useful in generating a rich understanding of participants' experiences and beliefs. 12 Suggested criteria for using focus groups include: 13

As a standalone method, for research relating to group norms, meanings and processes

In a multi-method design, to explore a topic or collect group language or narratives to be used in later stages

To clarify, extend, qualify or challenge data collected through other methods

To feedback results to research participants.

Morgan 12 suggests that focus groups should be avoided according to the following criteria:

If listening to participants' views generates expectations for the outcome of the research that can not be fulfilled

If participants are uneasy with each other, and will therefore not discuss their feelings and opinions openly

If the topic of interest to the researcher is not a topic the participants can or wish to discuss

If statistical data is required. Focus groups give depth and insight, but cannot produce useful numerical results.

Conducting focus groups: group composition and size

The composition of a focus group needs great care to get the best quality of discussion. There is no 'best' solution to group composition, and group mix will always impact on the data, according to things such as the mix of ages, sexes and social professional statuses of the participants. What is important is that the researcher gives due consideration to the impact of group mix (eg, how the group may interact with each other) before the focus group proceeds. 14

Interaction is key to a successful focus group. Sometimes this means a pre-existing group interacts best for research purposes, and sometimes stranger groups. Pre-existing groups may be easier to recruit, have shared experiences and enjoy a comfort and familiarity which facilitates discussion or the ability to challenge each other comfortably. In health settings, pre-existing groups can overcome issues relating to disclosure of potentially stigmatising status which people may find uncomfortable in stranger groups (conversely there may be situations where disclosure is more comfortable in stranger groups). In other research projects it may be decided that stranger groups will be able to speak more freely without fear of repercussion, and challenges to other participants may be more challenging and probing, leading to richer data. 13

Group size is an important consideration in focus group research. Stewart and Shamdasani 14 suggest that it is better to slightly over-recruit for a focus group and potentially manage a slightly larger group, than under-recruit and risk having to cancel the session or having an unsatisfactory discussion. They advise that each group will probably have two non-attenders. The optimum size for a focus group is six to eight participants (excluding researchers), but focus groups can work successfully with as few as three and as many as 14 participants. Small groups risk limited discussion occurring, while large groups can be chaotic, hard to manage for the moderator and frustrating for participants who feel they get insufficient opportunities to speak. 13

Preparing an interview schedule

Like research interviews, the interview schedule for focus groups is often no more structured than a loose schedule of topics to be discussed. However, in preparing an interview schedule for focus groups, Stewart and Shamdasani 14 suggest two general principles:

Questions should move from general to more specific questions

Question order should be relative to importance of issues in the research agenda.

There can, however, be some conflict between these two principles, and trade offs are often needed, although often discussions will take on a life of their own, which will influence or determine the order in which issues are covered. Usually, less than a dozen predetermined questions are needed and, as with research interviews, the researcher will also probe and expand on issues according to the discussion.

Moderating a focus group looks easy when done well, but requires a complex set of skills, which are related to the following principles: 15

Participants have valuable views and the ability to respond actively, positively and respectfully. Such an approach is not simply a courtesy, but will encourage fruitful discussions

Moderating without participating: a moderator must guide a discussion rather than join in with it. Expressing one's own views tends to give participants cues as to what to say (introducing bias), rather than the confidence to be open and honest about their own views

Be prepared for views that may be unpalatably critical of a topic which may be important to you

It is important to recognise that researchers' individual characteristics mean that no one person will always be suitable to moderate any kind of group. Sometimes the characteristics that suit a moderator for one group will inhibit discussion in another

Be yourself. If the moderator is comfortable and natural, participants will feel relaxed.

The moderator should facilitate group discussion, keeping it focussed without leading it. They should also be able to prevent the discussion being dominated by one member (for example, by emphasising at the outset the importance of hearing a range of views), ensure that all participants have ample opportunity to contribute, allow differences of opinions to be discussed fairly and, if required, encourage reticent participants. 13

Other relevant factors

The venue for a focus group is important and should, ideally, be accessible, comfortable, private, quiet and free from distractions. 13 However, while a central location, such as the participants' workplace or school, may encourage attendance, the venue may affect participants' behaviour. For example, in a school setting, pupils may behave like pupils, and in clinical settings, participants may be affected by any anxieties that affect them when they attend in a patient role.

Focus groups are usually recorded, often observed (by a researcher other than the moderator, whose role is to observe the interaction of the group to enhance analysis) and sometimes videotaped. At the start of a focus group, a moderator should acknowledge the presence of the audio recording equipment, assure participants of confidentiality and give people the opportunity to withdraw if they are uncomfortable with being taped. 14

A good quality multi-directional external microphone is recommended for the recording of focus groups, as internal microphones are rarely good enough to cope with the variation in volume of different speakers. 13 If observers are present, they should be introduced to participants as someone who is just there to observe, and sit away from the discussion. 14 Videotaping will require more than one camera to capture the whole group, as well as additional operational personnel in the room. This is, therefore, very obtrusive, which can affect the spontaneity of the group and in a focus group does not usually yield enough additional information that could not be captured by an observer to make videotaping worthwhile. 15

The systematic analysis of focus group transcripts is crucial. However, the transcription of focus groups is more complex and time consuming than in one-to-one interviews, and each hour of audio can take up to eight hours to transcribe and generate approximately 100 pages of text. Recordings should be transcribed verbatim and also speakers should be identified in a way that makes it possible to follow the contributions of each individual. Sometimes observational notes also need to be described in the transcripts in order for them to make sense.

The analysis of qualitative data is explored in the final paper of this series. However, it is important to note that the analysis of focus group data is different from other qualitative data because of their interactive nature, and this needs to be taken into consideration during analysis. The importance of the context of other speakers is essential to the understanding of individual contributions. 13 For example, in a group situation, participants will often challenge each other and justify their remarks because of the group setting, in a way that perhaps they would not in a one-to-one interview. The analysis of focus group data must therefore take account of the group dynamics that have generated remarks.

Focus groups in dental research

Focus groups are used increasingly in dental research, on a diverse range of topics, 16 illuminating a number of areas relating to patients, dental services and the dental profession. Addressing a special needs population difficult to access and sample through quantitative measures, Robinson et al . 17 used focus groups to investigate the oral health-related attitudes of drug users, exploring the priorities, understandings and barriers to care they encounter. Newton et al . 18 used focus groups to explore barriers to services among minority ethnic groups, highlighting for the first time differences between minority ethnic groups. Demonstrating the use of the method with professional groups as subjects in dental research, Gussy et al . 19 explored the barriers to and possible strategies for developing a shared approach in prevention of caries among pre-schoolers. This mixed method study was very important as the qualitative element was able to explain why the clinical trial failed, and this understanding may help researchers improve on the quantitative aspect of future studies, as well as making a valuable academic contribution in its own right.

Interviews and focus groups remain the most common methods of data collection in qualitative research, and are now being used with increasing frequency in dental research, particularly to access areas not amendable to quantitative methods and/or where depth, insight and understanding of particular phenomena are required. The examples of dental studies that have employed these methods also help to demonstrate the range of research contexts to which interview and focus group research can make a useful contribution. The continued employment of these methods can further strengthen many areas of dentally related work.

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Gill, P., Stewart, K., Treasure, E. et al. Methods of data collection in qualitative research: interviews and focus groups. Br Dent J 204 , 291–295 (2008). https://doi.org/10.1038/bdj.2008.192

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[Focus group interview as a qualitative research method]

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Focus group research is a qualitative method with interesting properties. It is performed by planned discussion and interview with a small group of people conducted by a moderator. The participants are sampled from the study population. The aim is to obtain knowledge of the participant's considerations and ideas on a specific topic. The method is feasible in illuminating the variation of viewpoints held in a population. It is used as a single source of data or in combination with other methods. As the method provides data in a social context it is used as an alternative to individual interviews, when appropriate, or in the initial development of a questionnaire. The focused interviews is feasible in methodological triangulation or when other methods are suboptimal. Focus group interviews is considered to be of value in health research.

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The Citizen Social Science Training Program is designed to be implemented by residents in their own community, equipping local citizens to build capacity and develop industry-standard data management skills at the grassroots level. Industry standards ensure integrity and value of data, an important quality for findings to be accepted and leveraged, both near and far. This qualitative data training will help you learn best practices to collect, analyze, and report textual data collected from interviews or focus groups.

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Extract insights from Customer & Employee Interviews. At Scale.

Top qualitative data analysis techniques for focus groups.

Home » Top qualitative data analysis techniques for focus groups

Focus Group Insights play a crucial role in understanding the underlying motivations of participants during discussions. These insights are invaluable in identifying trends, pain points, and unique perspectives that emerge from group interactions. As businesses aim to make data-driven decisions, capturing the essence of these discussions can significantly inform product development, marketing strategies, and overall customer satisfaction.

Effective analysis of focus group data requires various qualitative techniques to uncover hidden patterns. By systematically exploring participant feedback, organizations can derive actionable insights that lead to enhanced services and improved user experiences. Understanding how to implement these analysis techniques is essential for maximizing the value of focus group discussions.

Common Qualitative Analysis Methods

In qualitative research, analyzing data from focus groups yields valuable insights into participants’ perceptions and experiences. Common qualitative analysis methods help researchers interpret these focus group insights effectively. Thematic analysis is one such approach, where researchers identify and analyze key themes that arise from the discussions. This method focuses on patterns across participant responses, allowing for a nuanced understanding of shared experiences and differences.

Another significant method is content analysis, which entails a systematic examination of verbatim transcripts. In this process, researchers code and categorize responses to uncover underlying meanings and trends. Additionally, narrative analysis can be employed to explore individual stories and how they relate to broader themes within the group. By employing these qualitative analysis methods, researchers can ensure that focus group insights are thoroughly examined and translated into actionable findings that inform decision-making and strategy.

Thematic Analysis for Focus Group Insights

Thematic analysis plays a critical role in deriving meaningful Focus Group Insights from qualitative data. This method allows researchers to identify, analyze, and report patterns or themes within the data gathered from focus group discussions. By systematically organizing the wealth of information gathered, thematic analysis offers a clearer understanding of participant sentiments, behaviors, and pain points.

To effectively conduct thematic analysis, consider these key steps: First, familiarize yourself with the data by reading through transcripts thoroughly. Then, generate initial codes that capture important features of the content. Next, search for themes by collating related codes into overarching themes. After that, review the themes to ensure they accurately represent the data. Finally, define and name each theme, providing insights and context to draw actionable conclusions. This structured approach ensures that your Focus Group Insights not only reflect participants' voices but also provide valuable information for making informed decisions.

Content Analysis Techniques

Content analysis techniques provide an effective means to interpret focus group insights. By systematically examining conversation transcripts, researchers can identify patterns and recurring themes that emerge from discussions. This approach not only aids in synthesizing large volumes of qualitative data but also enhances understanding of participants' perspectives, enabling deeper insights into their motivations and experiences.

Several techniques stand out in the realm of content analysis. First, thematic analysis involves categorizing data into themes for further examination. Next, sentiment analysis gauges emotional tone, providing additional context to participants’ feelings on specific topics. Additionally, coding responses can efficiently aggregate similar ideas, allowing for a clearer visualization of dominant views. Ultimately, implementing these techniques will transform raw focus group insights into actionable intelligence that informs decision-making and strategy development.

Advanced Focus Group Insights

Advanced Focus Group Insights can illuminate key patterns and themes from gathered data. Analyzing qualitative data from focus groups requires structure to uncover action-oriented insights. Focus Group Insights enable researchers to dive deep into participants' sentiments, behaviors, and underlying motivations. By rigorously categorizing these insights, professionals can identify significant trends and themes that inform strategic decisions.

To extract valuable outcomes from focus groups, consider key techniques. First, pinpoint themes by reviewing participant interactions, analyzing quotes for context. Next, create a synthesis of insights tied to specific goals, such as customer retention and engagement. Finally, attribute insights to individual participants for accuracy and deeper understanding. By focusing on these elements, researchers can ensure clarity and precision in their analysis, leading to actionable Findings that truly reflect participant views and experiences. This approach not only enriches the insights gathered but also enhances the overall quality of qualitative research.

Grounded Theory Approach

Grounded Theory Approach is an analytical method that seeks to generate theories from qualitative data rather than testing existing hypotheses. In focus groups, this approach allows researchers to develop insights based on participants' experiences and perspectives. This is invaluable for understanding the nuances of group dynamics and collective viewpoints.

In applying this approach, researchers typically follow several key steps. First, they collect data through focus group discussions, ensuring rich and varied contributions from participants. Next, they engage in open coding, a process where they identify themes, concepts, and patterns within the dialogue. Subsequently, axial coding connects these categories, revealing relationships and deeper meanings behind participants' comments. Finally, selective coding helps in forming a cohesive narrative that encapsulates the overarching themes derived from Focus Group Insights. Through this iterative process, researchers can effectively build theories that are rooted in participants’ lived experiences, enhancing the overall understanding of the subject matter.

Narrative Analysis for Focus Groups

Narrative analysis for focus groups delves into how participants convey their thoughts and experiences. This technique emphasizes understanding the stories shared during discussions, revealing deeper insights that might otherwise go unnoticed. By examining the narrative structure, researchers can uncover themes that resonate throughout the group, offering valuable focus group insights.

In narrative analysis, it is vital to consider three main aspects: context, content, and meaning. First, understanding the context in which the narratives are shared helps researchers grasp the motivations and emotions behind participants' responses. Second, analyzing the content ensures that the specific words and phrases used are carefully considered, as they can highlight unique perspectives. Lastly, exploring the underlying meanings reveals attitudes and beliefs that influence participants' behaviors, enriching the overall understanding of the topic at hand. This comprehensive approach not only amplifies the focus group insights but also fosters a more nuanced interpretation of qualitative data.

Conclusion on Harnessing Focus Group Insights

Harnessing Focus Group Insights provides organizations with a deeper understanding of their target audience’s perspectives. By analyzing qualitative data from focus groups, teams can uncover motivations, pain points, and preferences that guide decision-making processes. Each insight, backed by compelling quotes or evidence, allows for a more informed recruitment strategy or product development approach, ultimately driving customer satisfaction.

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Reconciling Methodological Paradigms: Employing Large Language Models as Novice Qualitative Research Assistants in Talent Management Research

• Bhaduri, Sreyoshi
• Kapoor, Satya
• Mittal, Anshul
• Mulkar, Rutu

Qualitative data collection and analysis approaches, such as those employing interviews and focus groups, provide rich insights into customer attitudes, sentiment, and behavior. However, manually analyzing qualitative data requires extensive time and effort to identify relevant topics and thematic insights. This study proposes a novel approach to address this challenge by leveraging Retrieval Augmented Generation (RAG) based Large Language Models (LLMs) for analyzing interview transcripts. The novelty of this work lies in strategizing the research inquiry as one that is augmented by an LLM that serves as a novice research assistant. This research explores the mental model of LLMs to serve as novice qualitative research assistants for researchers in the talent management space. A RAG-based LLM approach is extended to enable topic modeling of semi-structured interview data, showcasing the versatility of these models beyond their traditional use in information retrieval and search. Our findings demonstrate that the LLM-augmented RAG approach can successfully extract topics of interest, with significant coverage compared to manually generated topics from the same dataset. This establishes the viability of employing LLMs as novice qualitative research assistants. Additionally, the study recommends that researchers leveraging such models lean heavily on quality criteria used in traditional qualitative research to ensure rigor and trustworthiness of their approach. Finally, the paper presents key recommendations for industry practitioners seeking to reconcile the use of LLMs with established qualitative research paradigms, providing a roadmap for the effective integration of these powerful, albeit novice, AI tools in the analysis of qualitative datasets within talent

• Computer Science - Computers and Society;
• Computer Science - Artificial Intelligence

• Open access
• Published: 26 August 2024

Health care needs and barriers to care among the transgender population: a study from western Rajasthan

• Tanvi Kaur Ahuja 1 ,
• Akhil Dhanesh Goel 1 , 2 ,
• Manoj Kumar Gupta 1 , 2 ,
• Nitin Joshi 1 ,
• Annu Choudhary 1 ,
• Swati Suman 1 ,
• Kajal Taluja 1 ,
• Madhukar Mittal 3 ,
• Navdeep Kaur Ghuman 4 ,
• Navratan Suthar 5 &
• Pankaj Bhardwaj 1 , 2  

BMC Health Services Research volume  24 , Article number:  989 ( 2024 ) Cite this article

Metrics details

Transgender people comprise an estimated 0.3–0.5% (25 million) of the global population. The public health agenda focuses on understanding and improving the health and well-being of gender minorities. Transgender (TG) persons often have complex healthcare needs and suffer significant health disparities in multiple arenas. The international literature suggests that this community is at a higher risk of depression, and other mental health problems, including HIV. Many transgender people experience gender dysphoria and seek specific medical needs such as sex reassignment surgeries, implants, hormonal therapies, etc., but are unable to access these services due to financial or social reasons. The objective of this study was to assess the healthcare needs and associated barriers experienced by transgender people in Western Rajasthan. Methodology: A qualitative study was carried out in which multilevel stakeholder interviews were conducted using interview and focus group discussion guides. Data was analyzed using the qualitative thematic analysis technique. Results: Findings reveal that transgender people have expressed their need to access health services for general health needs, including but not limited to mental health, non-communicable diseases, and infectious diseases. Barriers to healthcare services were identified on 3 levels: health system, social and personal. Health system barriers include policy, accessibility, affordability, and acceptability issues. Social factors such as inadequate housing, education, and job opportunities also play an important role in affecting the individual’s health-seeking behavior. The knowledge of healthcare providers in this context was also limited in context of health insurance schemes, package of services available for transgenders and the importance of gender sensitive healthcare. Conclusion: Transgender people expressed the need for mental health services, programs targeting nutritional improvement, gender-affirmation procedures besides regular screening of non-communicable diseases as operational for males and females. Levels of barriers have been identified at various levels ranging from absence of targeted policies to individual behavior.

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Introduction

Universal Health Coverage (UHC) means that all people have access to quality healthcare services (service coverage) without any financial hardships (catastrophic health expenditure) [ 1 ]. To achieve UHC, National Health Policy 2017 projects to increase the government’s health expenditure to 2.5% of GDP by 2025 [ 2 ]. In alignment with this objective, the budgeted health sector spending has increased from 1.3% (2019-20) to 2.1% of GDP (2021–2022). According to National Health Accounts 2018-19, Out of Pocket Expenditure per capita (in Rupees) is 2155 [ 3 ].

Incidence of catastrophic health spending is felt at a higher rate by vulnerable communities due to gender, socio-economic position, disability status, or sexual orientation, besides other characteristics. The Transgender (TG) community is one such community whose gender expression (masculine, feminine, other) differs from their assigned sex (male, female) at birth. They can be identified as trans-man or trans-woman [ 4 ]. In the Indian context, transgender individuals identify themselves differently including Hijras, Aravanis, Kothis, Jogtas/Jogappas, and Shiv-Shakthis. For the first time, this population was included in India’s 2011 census. Reports suggest that 4.8 million Indians identified themselves in the ‘other’ category.

Recent legal and policy changes in India have significantly affected gender-diverse communities. The Transgender Persons (Protection of Rights) Bill formulated in 2014 went through changes over a period of 5 years and was finally declared an Act in 2019. The Act highlighted the need to prohibit discrimination including denial of service or unfair treatment in relation to healthcare [ 5 ]. With respect to UHC, there are evident disparities in service coverage across the transgender population [ 6 ]. Transgender persons face a disproportionate burden of certain diseases, including HIV, viral hepatitis, and other sexually transmitted infections. They also pose a higher risk for mental health issues or substance abuse. Literature also suggests that transgenders may seek gender-affirming health services apart from general healthcare services. This might involve counseling support for themselves and their family related to gender id entity or undergoing gender transitioning procedures and surgeries. Transition-related treatment may include cross-sex hormonal therapy, hair removal, and gender-affirming surgeries.

In India, there are significant disparities in the availability and accessibility of healthcare. Existing research has identified various challenges and barriers encountered by transgenders in accessing and navigating the healthcare system. These include a lack of provider expertise in transgender care, the gap in health systems delivery mechanisms, lack of culturally sensitive healthcare training, inadequate financial coverage or low socio-economic condition, and poor community health-seeking behavior [ 7 ]. Rajasthan is one of the high focus states under the National Health Mission [ 8 ]. Since Western Rajasthan is a desert area, healthcare becomes even more challenging [ 9 ]. It further causes adverse impact on the desire and ability of transgender people to access healthcare. Poor healthcare access and health outcomes among the transgender population can also be attributed to lower levels of health literacy [ 10 ]. Rajasthan is one of the states with the lowest literacy rates among the transgender population [ 11 ].

In order to improve the health of transgenders and address the barriers to healthcare, it is crucial to identify the health priorities. A growing body of research regarding the healthcare experiences of transgenders exists worldwide, but there is still a paucity of research in the Indian context. This study has been conducted with the aim of reviewing the health issues and challenges faced by them in the existing healthcare system in Western Rajasthan. Although behavioral and social factors play a pivotal role in transgender health, this research focused on health needs and healthcare system-related barriers and challenges.

Research questions:

What are the basic health needs of the transgender community?

What are the barriers they encounter in the process of obtaining healthcare services?

How are the experiences of transgender persons in healthcare facilities?

What is the level of knowledge among healthcare providers regarding health of transgender persons?

How can healthcare services be enhanced for the transgender population?

Methodology

The study was conducted in the state of Rajasthan during the year 2022.

Research Design: This study utilizes a descriptive qualitative research design to allow in-depth insight into the existing health-related needs of transgender persons, their experiences in healthcare facilities and the barriers they encounter in meeting their needs. The study was approved by the Institutional Review Board of All India Institute of Medical Sciences, Jodhpur in July 2022.

Setting: The study was conducted in a community-based organization.

Sampling and sample size: Purposive sampling was utilized for this research. Transgender people above or equal to 18 years of age residing in different geographical region of western Rajasthan were approached with the help of established Civil Service Organizations (CSO). People who responded back were included in the study.

Data collection: All recruitment and data collection procedures were completed by public health scholars trained in research under the supervision of a community medicine professor. Multi-stakeholder interviews were conducted. It includes identification of relevant stakeholders to understand facilitators and barriers of the topic of interest. The identified stakeholders included specialist healthcare providers, representatives of civil service organizations and transgender persons (target population). All the individuals who agreed to participate in the study were approached by the interviewer. They were explained the purpose of the study and an appropriate time was decided to ensure active participation. This was also done keeping in view the sensitivity of the subject matter. All the interviews and the focus group discussion were conducted face-to-face in English and translated to Hindi for participants who did not understand English. Key informant interviews ( n  = 7) of specialist healthcare providers central to providing transgender care were conducted. The specialists included of a psychiatrist, plastic surgeon, endocrinologist, gynecologist, and community medicine experts. All interviews with specialist healthcare providers had a duration of 20–30 min. Transgenders residing in different geographical region of western Rajasthan were invited for a focus group discussion (FGD). Informed consent was taken from all the study participants who agreed to participate in the study. Audio and video recordings were done for focus group discussion as well as key informant interviews. The focus group discussion lasted for 2 h. Apart from this, CSO representatives were also interviewed ( n  = 3) i.e., a nurse, social worker and the administrative head of the organization. Data was collected over a period of 2 months.

Before the focus group, socio-demographic data was recorded, including age, gender, education, and income. An FGD guide and interview schedules were prepared and used for focus group and key informant interviews, respectively. They were designed to cover information about:

Knowledge and experience on transgender issues.

Challenges in providing transgender care.

Methods for improvement of the healthcare system.

Analytic approach: Audio-recorded focus group data and key informant interviews were transcribed and translated into English by four researchers. The data obtained through key informant interviews were also transcribed. The data was analyzed manually using thematic analysis. The available data was actively and repeatedly read to familiarize and valuably orient towards the available raw data. Subsequently, codes were identified using an inductive approach i.e., they were reflective of the issues that were apparent in the data and were not dependent or guided by any existing theoretical frameworks. In the next step, themes were constructed by analyzing, combining, and comparing codes. The developed themes were such that they reflected the significance of the entire dataset. Lastly, the themes were reviewed, defined, and named, along with the identification of narratives that justify and explain all the mentioned themes. In the final stage of analysis, the identified themes from the coded data were used to construct a framework using grounded theory approach such that it accurately represents a concise picture of the data.

Ethical considerations: Confidentiality emerged as an ethical concern in this study. All transgender individuals were provided with detailed information about the purpose, procedures, potential risks, and benefits of research. Participants were ensured that their participation was voluntary, and they had the right to withdraw at any time without consequence. All data and identifying information collected during the discussion was restricted to the research team and anonymized to prevent identification of individual participants.

A total of 12 transgenders participated in the FGD. Their socio-demographic characteristics are summarized in Table  1 . All Participants in the study belonged to Rajasthan, India. Eleven out of the total 12 participants self-identified themselves as transgender woman. The mean age of transgender individuals who participated in the study was 23.8 ± 3.6. The selected cohort represented a range of educational qualifications from secondary school to post-graduation. The majority of the participants were employed, but none was employed in the government sector. More than half of the participating individuals had an income of less than INR 10,000 (66.7%) (Table  1 ).

Health needs of the transgender community

The need for regular screening of non-communicable diseases at peripheral healthcare centers was expressed by the transgender participants. Lack of accessible and/or affordable health services and social barriers contribute to anxiety and depression among them, which further leads to their inability to control the use of tobacco and alcohol. This indicates the need for mental health support tailored specifically for this population.

Healthcare provider 1 (HCP-1) “ Gender dysphoria is diagnosed in later stages of life, late adolescence, or early adulthood because individuals are not able to seek help due to a lack of knowledge on available medical options and familial pressure.”

Specifically, they expressed the need for public healthcare facilities to provide gender transitioning procedures ranging from hormone replacement therapies to sex reassignment surgeries.

Figure  1 illustrates coding tree for health needs of transgender participants.

Coding tree for health needs of transgender participants

Barriers enumerated by transgenders in accessing healthcare services were segregated into personal, healthcare system and social barriers (Table  2 ).

Personal barriers

Transgender participants revealed a lack of awareness regarding the provision of transgender identity cards being issued by the Ministry of Social Justice and Empowerment. Moreover, the growing need was identified to educate them regarding their entitlements which may have implications on health. These include but are not limited to recognition of their gender identity, provision of medical facilities for their surgical and hormonal needs, and facilitation of access in hospitals and other healthcare facilities. (Transgender Act 2019)

During a key informant interview, one of the medical practitioners highlighted the need to introduce and explain the range of medical options available to transgenders for their transition.

HCP-2 “ Internationally, I have worked in fertility clinics. Before undergoing hormonal therapies or surgeries, transgender patients usually preserve oocytes and sperms to bear children in the future. The basket of available options must be known to the community. This also improves their quality of life.”

The health outcomes of an individual are dependent on their timely health-seeking behaviors. An interview revealed that many transgenders prefer the traditional removal method of male genitals rather than conventional gender affirming surgery. This reflects multiple dimensions such as lack of awareness regarding appropriate health practitioners and discrimination by the qualified professionals. Other underlying reasons for this include the lack of public hospitals providing these services and the unaffordable costs of surgeries. A study participant has also revealed being comfortable getting the surgery done by the ‘guru’ . Moreover, the distance between their households and healthcare facility makes it inaccessible for them.

Health system barriers

Both transgender persons and healthcare providers reported a lack of knowledge of any insurance schemes specifically for transgenders or insurance coverage for the minority population under the available schemes. Their awareness regarding the inclusion of gender-specific needs such as sexual reassignment surgeries or hormonal therapies in the existing insurance schemes was limited.

The study participants also addressed the need for the inclusion of a third gender column in the patient information / outpatient cards across all the hospitals. This is in alignment with the Transgender Persons (Protection of Rights) Bill, 2019, which prohibits discrimination against them in healthcare [ 5 ]. It would also lead to a transgender-inclusive environment in the hospital and greater acceptance by other people.

TG participant 7 “ Whenever we go to the hospital, we are asked whether to write male or female. There is no option of transgender in the OPD cards.”

In India, nationally recognized identity cards are being provided by the Ministry of Social Justice and Empowerment as a step towards mainstreaming their identity. One participant revealed that recently when she visited a hospital, the authorities denied accepting the TG identity card. This incident reflects the need of generating awareness across all sectors, including healthcare, to prevent the exclusion of transgender people in society.

TG participant 8 I had fever for a few days, I went to a hospital for treatment. I gave my transgender ID card issued by the ministry. They said this is not valid.

Accessibility

Majority of the participants revealed having negative experiences in healthcare settings. They reported that they had to wait very long to access health services.

One participant complained about the long counselling procedure and time to access hormone replacement therapy. Furthermore, many qualified practitioners discourage and demotivate the use of hormones. This reluctance among medical practitioners to prescribe hormones often compels transgenders to refer to the unfiltered content on the internet, resulting in the self-administration of hormones. Since transgenders are unaware of the side effects of unregulated dosages of hormones, it can result in adverse health outcomes.

Sometimes, the health facilities with available resources are situated far away from the residence of transgenders leading to difficulty in access. In one of the key informant interviews, a medical practitioner shared her experience with a transgender patient whose vaginal canal got stenosed as a complication of post Sex Reassignment Surgery (SRS). Since the health facility was around 500 km from her hometown, she could not reach the hospital on time.

Availability

One of the most significant barriers to healthcare reported by transgenders was a dearth of healthcare providers trained to address their specific health problems. Healthcare providers also emphasized the need for training to understand the best practices for their care. Some parts of clinical training should also include the importance and impact of physician-patient communication. The use of correct pronouns should be taught to collect sufficient and accurate information on their gender identity and thus, making the hospital settings friendly for them. Additionally, awareness sessions should also be conducted for medical professionals to make them comfortable and culturally competent while dealing with this section of society.

Some participants also shared that there is a need for designated facilities in healthcare, such as separate queues in OPDs and dedicated wards or beds in hospitals. It was felt that these facilities’ absence contributed to their fear and delay in access and utilization of desired appropriate care. Due to contributory social factors, such as real or perceived stigma, it is challenging for them to accommodate within the general ward. Medical providers had contrasting views in lieu of the unavailability of designated facilities. While most believed that providing separate queues and beds for them in hospitals was essential, one of the doctors felt this would promote social exclusion.

TG participant 1 Where should we stand in hospitals? Queues made for males or females? Separate beds shall be assigned for us so that we can access the services without hesitancy or fear of discrimination . HCP-3 Providing them separate facilities for all services cannot be the ultimate solution. Will this promote equity or rather advance social exclusion? We should think about it.

Moreover, there is a lack of specialist care in hospitals that are accessible to them. There is no provision to address transgender-specific health problems at the primary healthcare level. Lack of robust referral mechanisms leading to delayed or denied care was also reported.

Affordability

Transgenders are not registered and do not have access to benefits under the insurance schemes functioning in the country. All hospitals in the country do not provide gender transition services. Those services provided by the private sector often have charges beyond their paying capacity. As a result, accessing and affording healthcare becomes a challenge for them. This is one reason that urges them to go to unqualified traditional medical practitioners for gender transitioning surgeries or ‘Dai Nirwan.’

Breast augmentation is another common procedure utilized by transgenders. One participant discussed the availability of various implant materials and how their costs vary depending on the quality. Additionally, due to financial reasons and lack of awareness, low-quality implant materials are utilized in surgeries, which increases their risk for breast cancer.

Social barriers

The non-medical factors play a crucial role in impacting health outcomes. Addressing social determinants is central to reducing existing health inequities. In this study, all the participants reported stigma and discrimination while sharing their experiences in healthcare settings. They further added that this discouraged them from utilizing available health services.

The participants reported that even the healthcare providers were uncomfortable with their presence and did not treat them like other patients.

Poor housing conditions and lack of job opportunities further push them into this vicious cycle of stigma and sickness. Transgenders have also reported experiencing psychological distress due to a lack of social support. Positive attitude and gender-supportive relationships in society can promote their well-being. The need for their inclusion in society through awareness generation by government initiatives was emphasized.

TG participant 3 We can promote family planning through condom advertisements, so why not involve transgender figures in government health awareness advertisements and campaigns .

Healthcare provider expertise in TG health

All the healthcare providers felt the need for training to improve physician-patient communication and transgender persons care. A culturally competent healthcare perspective is fundamental for treating the transgender population. Those providers who had experience with such patients were more likely to provide perspectives on their care and barriers than those who had never encountered such cases. They highlighted that very few transgender patients are registered in the hospitals of Rajasthan. This can be attributed to the stigma associated with their presence rather than assuming they do not wish to seek healthcare services.

This study sought to investigate and fill the gap in the domain of transgender healthcare. The purpose of the research was to characterize the health needs and barriers faced by transgender individuals in navigating through the health system. Previous international and Indian studies have reported a lack of transgender-sensitive care. The findings of this research corroborate this premise. There is a wide and serious gap between the population’s needs and the healthcare system’s ability to respond to these needs.

The socio-demographic profile of the participants in this study revealed that the income of the majority of the participants was below INR 10,000. This finding is in alignment with the results (70%) of a study conducted among transgenders in Vadodara, Gujarat, India [ 12 ].

The FGD gave an opportunity to the study participants to express their general and gender-specific health needs. The health needs of the participants in this study included available medical services common to the general population and certain specific transgender needs, particularly psychiatric support, hormonal therapies, and sex-reassignment surgeries. This is in accordance with the previous studies, which also identified general health problems that need to be addressed, including the high prevalence of diabetes and hypertension, substance abuse, anxiety, and depression [ 13 ].

Transgender individuals discussed a range of experiences and barriers encountered in the healthcare system in accessing the available services. The barriers were categorized at the healthcare system, social and individual levels. The system-level barriers ranged from policy issues to hospital or organizational problems. It included a lack of coverage for the transgender population in government health insurance schemes. The introduction of a comprehensive package master in the Ayushman Bharat scheme has now addressed the lack of coverage for transgenders in the existing insurance schemes. It includes the existing packages as well as specific packages for transgenders [ 14 ]. This paves the way for a new chapter in their care. The unavailability of trained healthcare providers is another major problem. In 2019, National Medical Commission (NMC) updated the medical education curriculum and added a new module on Attitude, Ethics, and Communication (AETCOM) competencies [ 15 ]. It could be used as an opportunity to introduce culturally sensitive communication training for medical professionals, especially focusing on LGBTQ + community, to advance our aim to achieve equity. In addition to the unavailability of trained doctors, the inaccessibility of healthcare facilities and unaffordability also negatively impact the people’s health. All these underlying factors contribute to their practice of getting surgeries done by traditional and untrained medical practitioners. These findings are consistent with another study conducted in India to assess the health-seeking behavior of transgender people. They also reported long waiting times in hospitals affecting their health behaviors and are confirmed to have undergone medical procedures performed by gurus or technicians [ 16 ].

The finding of concern that emerged in our study sample was the use of unprescribed hormone therapy. This finding is similar to a study conducted in Maharashtra to assess the practices related to hormonal therapy [ 17 ]. It states that participants reported going for unsupervised hormone replacement therapy due to unaffordability, lack of trained healthcare providers and prior experiences in healthcare settings [ 17 ]. In order to avail the hormonal therapy, transgender patients require to undergo psychological counseling’s for confirmation of gender dysphoria. In our study, transgender individuals felt that the psychotherapy sessions are too long, leading to a delay in the initiation of hormone replacement therapy. World Professional Association for Transgender Health (WPATH) mentioned in their Standards of Care (SOC) that any minimum number of sessions cannot be fixed and is an individualistic approach. It depends whether someone wishes to avail psychological support before, during, or throughout the transition process [ 18 ]. Gender transitioning may involve but not be limited to procedures such as hormonal therapy and sex reassignment surgeries. Moreover, there are only a few public health facilities providing gender-transition services and there is no government support in the form of subsidies to avail these services from a private hospital. The government, is however, working on extending and empaneling public and private hospitals in order to make these services accessible to the population.

This need assessment study also attempted to address the social determinants barring healthcare access. Stigma, discrimination, support from family and friends, and difficulty in seeking housing determine health and healthcare accessibility. These factors have also been highlighted by the study conducted in Vadodara, India [ 12 ]. It re-emphasizes the findings from our study that social determinants such as lack of economic and educational opportunities, rejection, and isolation from society have an impact beyond gender identity issues, rather, they pose a risk to the psychological status of the transgender population.

The health disparities and barriers to care faced by transgenders should be addressed to promote health equity and justice. Comprehensive approaches to improve access, utilization, and quality of healthcare services are currently lacking. These challenges can also be addressed at the following levels:

Individual Level.

Healthcare system Level.

Community Level.

Garima Greh facilities have been introduced as shelter homes for transgender individuals where basic amenities are being provided to them [ 19 ]. They can be utilized as launchpad sites to improve their awareness of their rights and available entitlements and medical interventions. IEC materials can be displayed at Garima Greh facilities for health promotion and modification of their health-seeking behaviors. Similar to ASHA workers who are community members working for their healthcare, volunteers can be appointed from their community. Training of these volunteers can be done (Training of Trainers) so that they can improve their health-seeking behavior, increase awareness, and aid in the overall empowerment of the community.

All hospitals and clinical settings shall provide a safe and welcoming environment for gender-diverse people [ 20 ]. The fact that their physical, mental, and cultural differences affect their behaviors must be known but, more importantly, understand these differences and assigning them value is the key. Actions can be taken to promote transgender identity across healthcare settings by displaying Information, Education and Communication (IEC) material regarding their health needs and promoting their acceptance in society – ‘This hospital is LGBTQIA + friendly.’ Transgenders can also be part of the healthcare system, whereby; they can act as resource persons and promote the inclusivity of gender-diverse individuals. Medical students shall be trained to communicate sensitively to the needs of transgenders, and doctors shall be trained in a culturally competent way to treat their gender-specific needs. To promote access and utilization of health services, specific transgender clinics are being set up across the country. All participants in the study felt this would help them to access available services without hesitancy. Separate general health camps for regular and dental check-ups can also aid in health promotion and equity. Another potential solution to promote transgender health is through digital solutions. Tele-consultation can be an effective way to address their needs as well as to protect them from social stigma and discrimination that hinder their access and utilization of available services.

According to World Health Organization (WHO), social determinants account for 30–55% of health outcomes [ 21 ]. The most effective way to address SDH is by action at the community level. General campaigns and community awareness sessions are essential to promote acceptance by the general population. Moreover, the study suggests that there is a need for awareness and sensitization of transgenders regarding the basket of medical options available for them such as techniques for fertility preservation.

In summary, the study demonstrates the health issues of transgenders and reflects upon the various factors influencing health and access to care. It urges the stakeholders to contemplate the need to safeguard the rights of transgenders by providing equitable access to the available resources.

This study is an attempt to explore health needs from beneficiary as well as service provider perspectives. Our findings are consistent with the previous literature. Findings from this study provide evidence base for future research and a helpful tool for the policymakers and advocates to better address the needs of transgender people.

The study’s major limitation was that only one focus group discussion was undertaken due to limited time and difficulty in accessing the desired population. However, one FGD allowed for exploration of issues related to transgender experiences and healthcare needs. It allowed the researchers to gather detailed narratives that might not emerge from individual interviews. Given the paucity of literature in the Western Indian context, a single focus group discussion can be valuable for informing advocacy efforts and policy reforms. Participants in the study were recruited through purposive sampling and did not differentiate between cultural identities of transgender persons; therefore, the results might vary geographically and according to the social context, thus, limiting the external validity. The health needs might vary between transgender male and female populations, but there was only one transgender male participant in our study. Additionally, the service providers’ knowledge was not directly assessed by explicitly questioning the standards of care.

Proposed framework

Based on study findings, a Gender Responsive Healthcare System Framework is designed. (Fig.  2 ) This framework illustrates and emphasizes on the need for planning, interventions, and actions at 3 levels – policy (a), health system (b), social, and individual (c) in alignment with the identified themes represented in Table  1 . The framework describes how the barriers can be addressed at these 3 levels to have a robust and gender-responsive healthcare delivery system in India.

The concept of healthcare is multi-dimensional. Combined action is required at the administrative, service provider and beneficiary level for a gender responsive healthcare system. Inclusion of the transgender population in existing health insurance schemes is central to reducing their out-of-pocket expenditure and helping them gain recognition in the society through the treatments that they wish to access. Outpatient cards in hospitals should include options of male, female and transgenders/others (gender diverse) creating a safe and welcoming environment. Existing health programs shall also target transgender population for reducing the burden of infectious diseases such as tuberculosis and non-communicable diseases. At the healthcare system level, medical professionals competent to provide transgender specific care and availability of specialists shall be ensured. A robust referral mechanism from primary healthcare centers to higher levels could ensure uninterrupted care for the transgender population. Moreover, hospitals have distinct queues, for men and women. There is a need to understand that gender is not a visibly readable or unchanging phenomenon, rather it is a social construct. Proper queue management can address not only the issues of stigma, but also make healthcare accessible to them. At an individual level, good health seeking behavior and familial support can aid in improving health outcomes. Altogether, these efforts at the policy, health system and individual level can lead to improvement in accessibility, availability, affordability and acceptability of services by the transgender people.

Gender Responsive Healthcare System Framework

This study has explored experiences of transgender people navigating through the healthcare system. These accounts have highlighted their health needs and the barriers they face in accessing care. They expressed the need for mental health services, programs targeting nutritional improvement, gender-affirmation procedures besides regular screening of non-communicable diseases as operational for males and females. Levels of barriers have been identified ranging from absence of targeted policies to individual behavior. Targeted efforts and intersectoral collaboration are required for effective establishment and delivery of healthcare services.

Data availability

The data generated and reviewed are fully available in this article and its supplementary files. For any further data, Dr. Tanvi Kaur Ahuja ([email protected] could be contacted).

All relevant data analyzed during this study are included in this published article and its Supplementary Information files.

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Acknowledgements

The authors would like to acknowledge the contribution of Sambhali trust, Jodhpur and Nai Bhor Sanstha, Jaipur for helping us to get in touch with the transgender participants.

This research received no funding.

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School of Public Health, All India Institute of Medical Sciences, Jodhpur, India

Tanvi Kaur Ahuja, Akhil Dhanesh Goel, Manoj Kumar Gupta, Nitin Joshi, Annu Choudhary, Swati Suman, Kajal Taluja & Pankaj Bhardwaj

Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences, Jodhpur, India

Akhil Dhanesh Goel, Manoj Kumar Gupta & Pankaj Bhardwaj

Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, Jodhpur, India

Madhukar Mittal

Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, Jodhpur, India

Navdeep Kaur Ghuman

Department of Psychiatry, All India Institute of Medical Sciences, Jodhpur, India

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Contributions

T.A., A.G. Conceptualized the research study done, A.G., M.G., N.J., P.B. framed the Methodology was framed, T.A., N.K., M.M., N.S., N.G., A.C. contributed in collection of data; T.A., A.G. prepared the Original draft; T.A., A.G., S.S., K.T. Reviewed and edited the manuscript; P.B. M.G., N.J. Supervised the research study, All authors have read and agreed to the published version of the manuscript.

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Correspondence to Tanvi Kaur Ahuja or Akhil Dhanesh Goel .

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The study was approved by the Institutional Review Board in July 2022. The certificate reference number granted by the Institutional Ethics Committee is AIIMS/IEC/2022/4023. Informed consent was taken from all participants who agreed to participate in the study. Participants were informed that they could withdraw consent to participate at any time during the interview. All methods were performed in accordance with the relevant guidelines and regulations.

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Ahuja, T.K., Goel, A.D., Gupta, M.K. et al. Health care needs and barriers to care among the transgender population: a study from western Rajasthan. BMC Health Serv Res 24 , 989 (2024). https://doi.org/10.1186/s12913-024-11010-2

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Received : 29 May 2023

Accepted : 18 April 2024

Published : 26 August 2024

DOI : https://doi.org/10.1186/s12913-024-11010-2

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