focus group discussions

A Rigorous Qualitative Study to Explore Type 1 Diabetes in Older Adults: Using the Total Quality Framework

Diabetic MedicineIn “Supporting the ‘lived expertise’ of older adults with type 1 diabetes: An applied focus group analysis to characterize barriers, facilitators, and strategies for self-management in a growing and understudied population” (Cristello Sarteau et al., 2024), the authors discuss their study among older adults (OAs, defined as adults 65 years of age or older) with type 1 diabetes concerning care management. This research consisted of nine in-person focus group discussions with a total of 33 OAs and caregivers.

Central to the design and implementation of this research was the Total Quality Framework (TQF) (Roller & Lavrakas, 2015). The authors selected the TQF due to their focus on rigor and a quality approach to investigate the lived experiences of OAs with type 1 diabetes.

To support rigorous research and reporting, we selected the Total Quality Framework (TQF), a comprehensive set of evidence-based criteria for limiting bias and promoting validity in all phases of the applied qualitative research process. (p. 2)

In this article, the authors provide a unique and useful table describing the rationale behind their methodological decisions pertaining to each component of the TQF, i.e., Credibility, Analyzability, Transparency, and Usefulness. For example, with respect to Credibility, the table offers a lengthy discussion of sample design, including the impact of limited resources on the recruitment process and why the size of each group discussion was kept to 4-5 participants. Other areas of discussion in the table include the coding format and identification of themes (Analyzability), complete disclosure of elements related to design, data collection, and analysis (Transparency), and “how the study should be interpreted, acted upon, or applied in other research context in the real world” (Usefulness). Importantly, readers are directed to areas within the article where they can read about the explanations of methodological decisions that go beyond the limited space of the table, e.g., definition of the target population.

This research “revealed, above all, the complex and dynamic nature of managing type 1 diabetes over the lifespan” and provided “valuable foundational information for future research efforts” (p. 13). In addition to the perceived strengths of the research, the authors’ quality approach also allowed for an informed discussion of the limitations (e.g., diversity in the sample). By way of the TQF Transparency component, the authors provide readers with the details they need to build on this research and move forward in defining care-management solutions for the OA population with type 1 diabetes. As the authors state, the TQF enabled them to “promote confidence in using results from our study to inform future decision-making” (p. 17).

Cristello Sarteau, A., Muthukkumar, R., Smith, C., Busby‐Whitehead, J., Lich, K.H., Pratley, R.E., Thambuluru, S., Weinstein, J., Weinstock, R.S., Young, L.A. and Kahkoska, A.R., 2024. Supporting the ‘lived expertise’of older adults with type 1 diabetes: An applied focus group analysis to characterize barriers, facilitators, and strategies for self‐management in a growing and understudied population. Diabetic Medicine, 41(1), e15156.

Roller, M. R., & Lavrakas, P. J. (2015). Applied qualitative research design: A total quality framework approach. Guilford Publications.

Focus Group Discussions: Is This the “Best” Method?

The following is a modified excerpt from Applied Qualitative Research Design: A Total Quality Framework Approach (Roller & Lavrakas, 2015, pp. 106-107), a qualitative methods text covering in-depth interviews, focus group discussions, ethnography, qualitative content analysis, case study, and narrative research.

In focus group discussions the best method?Are focus group discussions the “best” method for your qualitative research study? There are several considerations that are fundamental to the decision whether to use the focus group method. In particular, the researcher needs to pay attention to the suitability of group discussions based on the research objectives as well as the accessibility and receptivity of the target population.

Unlike the in-depth interview (IDI) method that benefits from the “naturalness” of the one-to-one approach, the more contrived environment of the focus group discussion may make the method less suitable under certain circumstances. For example, face-to-face (in-person or video) focus group research would not be appropriate for a state agency that wants to understand the credit needs of low-income residents of a small town, because the community’s narrow pool of these residents would necessitate recruiting people who may know each other and who may be reluctant or unwilling to share details of their lives, particularly as those details relate to credit. For similar reasons, face-to-face focus groups would not be advised for investigating sexual activity among teenagers in a close-knit community. And, group discussions would not be suitable when the objective of the research is to gain feedback on the usability of a new website (i.e., the ability to navigate the site and move easily around it to find needed information) because it is the individual interplay with this website that comes closest to mirroring its eventual use in the real world, and this can better be learned in an IDI setting, not a group discussion.

On the other hand, group discussions are ideal when the research topic is not highly sensitive and the dynamics of the group interaction can foster important insights relevant to the research objectives. For example, a researcher might use group discussions to investigate (a) reactions to a new mobile-phone concept in order to identify its perceived strengths and weaknesses, (b) perceptions of risk and risk-taking among firefighters, (c) material preferences and purchases among people who knit or crochet, (d) eating habits and food preferences among young people with diabetes, (e) attitudes toward changes in a nonprofit’s annual fundraising event among its program volunteers, (f) coping mechanisms and in-class techniques for calming elementary school students in emergency situations among teachers, and (g) informational needs among residents of a retirement facility.

From a Total Quality Framework perspective, a more productive group discussion (in any mode) is smaller in size—ideally, no more than 10 people—because it gives the moderator sufficient time to gain substantive, useful feedback from each group participant while also reducing any intimidation participants may feel from speaking in a larger group setting. This factor is why smaller group formats such as dyads (two-person group) and triads (three people) can be particularly useful in some situations. Toner (2009), for instance, describes the “more intimate interaction” she experienced in conducting dyads with Native Americans and Latinas as well as the “incredibly rich data” that resulted from these discussions. Her research is an example of how a small group size has the potential advantage of reaping in-depth information, not too dissimilar from an IDI.

 

Toner, J. (2009). Small is not too small: Reflections concerning the validity of very small focus groups (VSFGs). Qualitative Social Work, 8(2), 179–192. https://doi.org/10.1177/1473325009103374

A Holistic Approach to Qualitative Analysis

The complete individualWhen conducting a qualitative analysis of in-depth interview (IDI) and focus group discussion data, the first step is to maintain the completeness of each case or research event. This means developing and maintaining a holistic understanding (including the contextual nuances) pertaining to each individual in an in-depth interview study and each group of participants in focus group research. In this analytical approach, the researcher is centered on the entirety of each lived experience or group of experiences related to the phenomena under investigation and specific research objectives. And in this spirit, the researcher is not concerned with how to disentangle the data, e.g., by looking at word frequencies or using Post-it Notes. Coding until blue in the face, particularly in the beginning phase of analysis, has the potential effect of “slicing and dicing” participants’ lived experiences thereby weakening their unique contributions to the research study.

A holistic approach to analysis acknowledges that (1) these unique contributions to our research are central to why we conduct qualitative research and (2) importantly, qualitative researchers owe it to their participants — who have given so much of themselves for our purposes — to maintain the integrity of their lived experiences.

How does the researcher do this?

At the conclusion of each IDI or focus group discussion, the interviewer or moderator should reflect on their understanding of what was learned from the participant(s). To do this, the researcher will use their notes and the audio and/or video recording of the session. It is useful to use Excel or something similar to log the key takeaways associated with the research objectives. By doing this exercise after each IDI or group discussion, the researcher is absorbing a complete “picture” of each participant’s or group’s attitudes, behaviors, and experiences. From there, the researcher can look across participants or groups to contrast and compare.

Crucially, however, the researcher is not necessarily contrasting and comparing simply based on the use of terminology or other obvious, manifest content. Instead, the researcher considers the entirety of what they have learned about each individual or group of participants as revealed in a combination of obvious, subtle, and contextual interconnections within the data.

This holistic approach begins in the beginning — before transcripts and coding — and, with concerted effort, is maintained throughout the analysis process.