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Transformational potential of

focus group practice in

participatory action research

Lai Fong Chiu Nuffield Institute for Health, University of Leeds

A B S T R A C T

In Participatory Action Research (PAR), group processes are central in facilitating change and focus groups are widely used by action researchers. However, the epistemological basis upon which focus group practice is grounded has not been closely examined and its transformational role has been taken for granted. This might impede the development of the focus group as a distinctive research practice and the realization of its trans- formational potential. Against the background of three partici- patory action research projects carried out in the National Health Service of the UK, the author shares her experience of using a variety of focus group methods for facilitating change in health promotion practice. Practical examples are used to explore the relationships between focus group practice and its epistemo- logical grounding. It is suggested that the transformational potential of the focus group lies in the equal value placed on different ways of knowing by an extended epistemological framework and the dynamic of knowing and doing embedded in the PAR process.

Action Research

Volume 1(2): 165–183: 034207[1476-7503(200310)1:2] Copyright© 2003 SAGE Publications London, Thousand Oaks CA, New Delhi www.sagepublications.co.uk

A R T I C L E

K E Y W O R D S

• epistemology

• focus group

practice

• transformation

165

Although action research invariably permits the use of a wide range of methods to bring about desirable changes, group processes are central because of their potential in engaging participants in research activities. Focus groups are used by action researchers alongside other ‘orthodox’ methods such as surveys, question- naires and individual interviewing, so long as they help the ‘enlightenment and awakening of common peoples’ (Fals-Borda & Rahman, 1991, p. vi). However, overemphasis on the emancipatory goal has led to the underdevelopment of its systematic practice (Reason, 1993). Altrichter and Gestettner (1997) suggested that the inability to establish a coherent constructive methodological discourse might have contributed to the decline of action research in German-speaking countries. It has been found that in the recent two volumes of participatory devel- opment by Blackburn & Holland (1998a, 1998b), macro-political processes rather than the micro-processes of participation and change continue to dominate discourse in this area.

Critical examination of research methods and practice is a vital part of intellectual work, as it functions to improve our sensibility to the consequences of our practices and assumptions, and ultimately to the questions of quality and validity. Central to current methodological debates around the focus group method in conventional research is its transformational potential. However, action researchers have taken no part in these debates despite their widespread adoption of the method. Such lack of methodological clarity is at best likely to undermine our confidence in developing focus groups into a distinctive research practice, and at worst could lead to confusion, paralysis and inactivity.

Therefore, in this article, I will explore the transformational potential of focus group practice in PAR through my own experiences of a variety of focus group methods in three PAR projects carried out between 1990 and 2002. I will locate these experiences by recounting briefly the research context and outlining the extended epistemological framework upon which my focus group practice has been explicitly grounded. Finally, drawing on examples from these experiences, I will illustrate the limits and possibilities of focus group practice in facilitating change within an extended epistemological framework. It becomes clear that the adoption of focus group methods based on the extended epistemology of PAR has allowed not only opportunities for critical awareness-raising, but also the combination of focus groups with other capacity-building activities. In turn, this provides a systematic and focused way of managing the change process through problem-solving, decision-making and reflection.

The research context

In the UK, there is a consistent pattern of low uptake of cancer screening among minority ethnic women. However, a review of the literature in this area suggested

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that research into minority ethnic women and cancer screening suffers from many theoretical and methodological problems (Chiu, 2000). Consequently, many intervention studies have yielded inconclusive or contradictory results (Jepson, Clegg, Forbes, Lewis, Sowden & Kleijnen, 2000). Moreover, research in this area has tended to focus on the communicational and cultural deficits of minority women (Doyle, 1991; McAvoy & Raza, 1988; McAvoy & Raza, 1991; Naish, Brown & Denton, 1994), without addressing the social context. The narrow focus on language and culture as barriers to uptake of services has not only hindered a wider theoretical understanding of the problem, but also has had the effect of perpetuating ineffective health promotion practice.

In searching for an alternative way of conceptualizing the issue of cancer screening and minority ethnic women and of generating knowledge and practice that can address the issue in action, the National Health Service commissioned the author to carry out three action research projects consecutively between 1990 and 2002. To give readers a background of the evolution of these projects, their goals and outcomes are briefly described below.

Communicating breast screening messages to minority ethnic women – constructing a community health education model (1990–1993)

The objective of this project was to construct a community health education model for the dissemination of breast screening messages to minority ethnic women. Eight minority language groups were involved. The Community Health Educator (CHE) Model, in which lay members of the communities were involved in the planning, delivery and evaluation of health promotion activities, emerged as an outcome of this project (Chiu, 1993). In addition, the project resulted in the publication of the first breast screening training pack for minority women in the UK (Chiu, Knight & Williams, 1993). The results of the project and the dissemi- nation of the training pack through a national conference in 1993 provided the impetus for many health promotion colleagues to set up their own CHE schemes. The training pack has been widely used in the breast screening education of minority ethnic women.

Woman-To-Woman: promoting cervical screening to minority ethnic women in primary care (1995–1997)

The objective of the Woman-To-Woman (WTW) project was to test the CHE model in primary care for the promotion of cervical screening. Six medical general practices and six language groups across three health districts were involved. The outcomes of this project were: the successful application of the CHE model in the primary care setting; the employment by participating prac- tices of CHEs for health promotion in a number of areas in addition to cervical

Chiu Transformational potential of focus group practice • 167

screening; the publication and dissemination of the Woman-To-Woman Training Pack for Minority Women (Rotherham Health Authority, 1998); the distribution of the research report of this project (Chiu, 1998) to all Public Health Departments in the UK.

Straight Talking: communicating breast screening messages in primary care (2000–2002)

In collaboration with primary care health professionals in five general practices and women from four language/ethnic communities, the recently completed Straight Talking Project has investigated the usefulness of CHEs in communicat- ing breast health and screening messages to women from disadvantaged back- grounds. The project has provided further understanding of the potential and effectiveness of the CHE model and insights into the public health and health promotion capacity in the new primary care environment. A research report documenting the process and outcomes of the project has been published (Chiu, 2002a). A new and completely revised Breast Screening Pack has also been developed from this project (Chiu, 2002b).

The continued developments of the Community Health Educator model and health education and promotion resources are two significant themes of these projects.

Structuring focus groups – a three-stage cycle

Focus groups formed the backbone of key participatory activities (exploring, planning and decision-making) in a three-stage cycle, developed and used con- sistently in the three projects mentioned earlier. The three-stage research cycle is based on Kurt Lewin’s concept of action research as a tool for ‘rational social management’, in which changes could be brought about through a series of steps beginning with the examination of the general objective, followed by the development of an overall plan to reach that objective. The initial action step taken to reach the objective would be evaluated and modification and replanning would take place. This forms a rational basis of a cycle of planning, executing, evaluating, spiralling towards improvement of organizational practices (Lewin, 1946). This framework, coincidentally, mirrors contemporary practice (i.e. needs assessment, responding and reviewing progress), which is required in many pro- grammed activities in the NHS (Hart & Bond, 1995).

Operating in the social and political environment of the NHS in the UK, where conventional research dominates, it is, in my view, ever more important for action researchers to make their methods explicit as well as to demonstrate the capacity of such an approach in the systematic management of complex research

Action Research 1(1)168 •

processes. The three-stage cycle illustrated in Figure 1, provided the basis for research plans in our PAR projects. It also helped in the negotiation of involve- ment, as participants could at all times be clear about the extent of their commit- ments.

The following is a brief description of how focus group activities were structured in all of the three stages.

Stage 1 – problem identification

Focus groups’ activities are convened mainly to facilitate the identification of concerns and exploration of opinions and experiences among participants. Other activities such as preparing the communities, negotiating with stakeholders, and, most importantly, building relationships between communities, the hosting organization and related statutory agencies also happen in the first stage.

Stage 2 – solution generation

Based on the results obtained in Stage 1, participants are invited to contribute to the construction and implementation of a health intervention programme. At this point, some co-researchers might take on the role of Community Health Educators. Focus groups are conducted to formulate solutions, i.e. health inter- vention programmes, and to identify gaps in capacities for implementation of these programmes. Workshop programmes to promote critical learning and

Chiu Transformational potential of focus group practice • 169

Stage 1

Problem identification

Focus groups for women from different language/ethnic groups and for professionals

Facilitate experiential and prepositional knowing for actions in Stage 2

Stage 2

Solution generation

Focus groups held for construction of intervention programme

Facilitate practical know- ing and representational knowing

Stage 3

Implementation and evaluation

Focus groups held for problem solving and for evaluation

Facilitate critical reflection on change and consolidate different knowing(s)

Figure 1 A summary of the focus group activities in the three PAR projects.

Review

capacity building are then organized. Focus groups are also used to evaluate the effectiveness of learning in preparing participants to enter Stage 3 where the inter- vention programmes are implemented and evaluated.

Stage 3 – implementation and evaluation

This stage is characterized by a defined period for field activities subsumed under the intervention programme. Both professionals and CHEs test out their newly acquired knowledge and skills and address the problems previously identified in real-life settings. As day-to-day activities intensify, regular problem-solving focus groups are set up to deal with issues arising from implementation. Evaluative focus groups are held to facilitate reflection upon the intervention programme and the overall effectiveness of the project at its end.

Focus groups as a vehicle for participation

Focus groups are, in general, defined as group discussions organized to explore a set of specific issues or to confirm a hypothesis (Greenbaum, 1993; Krueger, 1994; Stewart & Shamdasani, 1990). However, there exists a variety of focus group methods developed by different disciplines and research traditions. In marketing, where most focus group methods flourish, practical procedures and techniques of running a focus group dominates much of the methodological discourse (e.g. Fern, 2001). In contrast, discourse among social researchers is dominated by questions of interactions, researcher–participant relationships, and the transformational value of focus groups (e.g. Cunningham-Burley, Kerr & Pavis, 1999; Johnson, 1996; Kitzinger, 1994).

Debunking the myths of focus groups, Morgan and Krueger (1993) sug- gested that the ‘rules’ of using focus groups are undependable as there are different reasons and purposes for using focus group methods across different disciplines of social science.

As the usage of focus groups proliferates, many vouch for their multiple applicability. Health and social researchers have suggested that focus groups are an appropriate method for exploring sensitive and embarrassing subjects by engaging participants in group interactions (Kitzinger, 1994), for health educa- tion (Basch, 1987), and for radical social transformation through consciousness raising and empowering participants (Johnson, 1996; Padilla, 1993). Given that the overall purpose of our projects was to bring about change in health promo- tion practice and given the sensitivity of the issues of cancer screening and the linguistic diversity of the minority groups involved, focus groups appeared to be an appropriate methodological choice.

Conventional research tends to abstract from reality, thus focus group

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designs within such a paradigm are inclined to be top down. For example, many ‘how to’ books recommend an optimal number of participants (between six and eight) and researchers are urged to carefully ‘sample’ their participants. From my experience, the formulation of focus group research strategy in PAR is decidedly bottom up. The sizes of groups and the populations from which they are drawn vary according to the key research problems and local conditions. For example, the first project (Breast Screening) mainly involved bilingual women from ini- tially eight language groups to explore womens’ health beliefs and receptivity to the new breast screening programme; the size of these groups tended to be between eight and 12. However, in the second project, mini-focus groups, con- sisting of three to four participants, were convened for recruiting ‘difficult to reach’ groups. These were designed for women who were more isolated and who resided in localities that had a low concentration of minority populations (e.g. small market towns in Northern England). The size of focus groups in the Straight Talking project was considerably larger (eight to 12). This was due main- ly to the project’s inner city location where there was a high concentration of minorities and where participants could be accessed through more established social infrastructures.

Two of the three projects also involved health professionals in the localities. The size of the professional groups was determined by the number of organiza- tions involved (for example, six health professionals were involved in the Woman-to-Woman project while only five were involved in the Straight Talking project).

Working with other minority ethnic groups on the project, the importance of linguistic and cultural skills for accessing and accurately interpreting minority communities’ experiences are paramount. By involving bilingual women from the communities as co-researchers, we had provided not only an environment where uninhibited discussion and expression of cultural nuances could take place (Egwu, 1992), but also an opportunity for community members to be actively involved in these projects. Co-researchers received intensive training to facilitate focus group discussions, in which, when possible, the use of mother tongue was actively encouraged. The co-researchers and I co-facilitated all the focus groups. Venues for these meetings varied from women’s homes to health centres.

Due to the constraints of space, I am unable to give full details here of how these focus groups were organized and evolved. However, Table 1 illustrates briefly how focus groups were adopted as a strategy to work with a range of minority ethnic groups and health professionals in different settings and for different purposes.

A total of 95 focus groups were conducted in these three projects. This number included all focus groups that had a specific purpose, ranging from: exploring perceptions; formulating intervention strategies; analysing training needs and collecting ideas for health education resources; to evaluating learning

Chiu Transformational potential of focus group practice • 171

Action Research 1(1)172 •

Table 1 Structuring focus groups in a three-stage cycle

Project title Communicating breast Women-To-Woman: Straight Talking:

screening messages Promoting cervical Communicating breast

to minority women screening among minority screening information

women in primary care in primary care

Language/ethnic African-Carribean (English), African-Caribbean (English) English (English)

group involved Bengali (Sylheti), Arabic (Yemeni), Bengali (Sylheti),

Cantonese, Gujarati, Hindi, Bengali (Sylheti), Chinese (Cantonese)

Punjabi (Sikh), Pakistani Chinese (Cantonese), and Pakistani (Mirpuri)

(Mirpuri) and Vietnamese Pakistani (Mirpuri) and

(Vietnamese or Cantonese) Vietnamese(Vietnamese or

Cantonese)

Education levels High education level Unspecified education Unspecified education

of participants level level

from minority

communities

Professionals None Practice nurses from Practice nurses from

involved six general practices five general practices

Locations Inner city with high Mixed geographical Mixed geographical

concentration of locations: a city and locations: a city and a

minority populations two small towns neighboring small town

Type of focus group

Exploratory 16 (communities) 7 (communities) 16 (communities)

1(professionals) 2 (professionals)

Solution generation 2 (CHEs) 1 (CHEs) 2 (CHEs)

(formulating 1 (professionals) 1 (professionals)

intervention & 1 (CHEs & professionals)

training needs)

Collective 6 (CHEs) 6 (CHEs) 8 (CHEs)

problem-solving 6 (professionals) 0 (professionals)

Creative ideas 1 (CHEs) 3 (CHEs) 2 (CHEs)

Evaluative 1 (CHEs) 7 (communities) 1 (CHEs)

1 (professionals) 1 (professionals)

1 (CHEs)

1 (professionals & CHEs)

Total no of

focus groups 26 36 33

and success. With all these groups, discussions were structured with discussion guides and formal data collection and analysis were carried out. Other group activities that took place, which were equally important but are excluded from this exploration, were structured learning workshops and resource production activities typically held for capacity building, so as to enable participants to implement their solutions in action.

While focus groups activities, as described, formed the main methodologi- cal architecture of the three PAR projects, other formal research methods were also used to meet the demands of emergent situations. For example, in the WTW project, individual interviewing was used when focus groups failed to capture the opinions of older women. And in the ST project, a quasi-experiment involving pre- and post-intervention interviews was instituted to examine the effectiveness of a particular change action in the programme when CHEs considered the inter- ventions were too complex to be rigorously tested in a short time-scale (within eight months).

Different purposes of the focus group activities that emerged in the research process called for different methods. In these projects, I adapted various focus group methods, which derived from both marketing and social research. However, flexibility gave rise to questions and concerns about the potential con- flicts using methods established in different paradigms. For example, the market- ing variety of the focus group is associated with positivism and is often seen by critics as a form of social engineering, with participants treated as passive subjects. The concern over power and control in the relationships between researchers and participants of this variety has led some social researchers to reject the ‘market-consumer model for focus groups’, as incompatible with the goal of transformation (Cunningham-Burley et al. 1999; Johnson, 1996). How- ever, from my experience, using focus groups as a tool for transformation does not necessitate the outright rejection of techniques that have been developed in market research. For example, I have accomplished many key explorations and experiential tasks in focus groups by using the technique of stimulus materials and/or exercises (Calder, 1977; Greenbaum, 1993) without which, facilitating a dialogical process might not have been possible and co-operative undertaking might have been minimal. I would suggest that as PAR researchers, the goal of bringing about desirable changes through participation and empowerment requires us to utilize the best methods available not only to facilitate understand- ing of participants’ concerns (Verstehen) but actions for change (Praxis). It is important that a variety of focus group methods, whether derived from sociologi- cal or marketing disciplines, are used to maximize possibilities of participation in PAR. This openness to method is not only desirable but is epistemologically grounded, an assertion to which my discussion now turns.

Chiu Transformational potential of focus group practice • 173

An extended epistemological framework

Although PAR researchers are explicit about their ideological and political com- mitment, their epistemological assumptions are often implicit. Hence, in commu- nicating with researchers in the wider community, PAR writings appear to be long on ideology but short on methodology, giving the impression that anything goes (Reason, 1994). The concern for the question of epistemology and methodology in action research was first raised by Reason (1993); and his critical challenge has begun to bear fruit. The recent publication on action research (Reason & Bradbury, 2001) has now provided a discussion of the epistemological issues from different perspectives e.g. liberationist, post-modernist, feminist and construc- tivist. Different methodological choices have also been presented under the head- ing – ‘Practices’. However, the linkage between methodology and epistemology is not always explicitly discussed in the exemplars. Before I venture to justify my own adoption of extended epistemology, I need to make explicit my ontological stand. I am wholly committed to a worldview in which there is a physical reality that exists independently of me, and in which social reality (particularly for adults) is inevitably mediated by language and other symbolic representations. The extended epistemology (i.e. the nature of knowledge(s) as proposed by Heron, 1981, 1992) which includes ways of knowing about the physical world, is com- patible with my worldview and the adoption of this framework is useful when applying the PAR approach in the health research context in UK. This means that I do not reject positivism but see it as one way to find out about the world so that I can make some decisions on how to act on it and within it. Through working in close proximity with many medical researchers, I have learned that to improve the health of the disadvantaged does not require the rejection of positivism; participa- tive medical practitioners who worked with me on these projects did not throw away their medical knowledge and training but drew on it to support community actions by passing on their knowledge to lay members. I came to recognize that if PAR is to truly address the plights of the powerless and to bring about social jus- tice, we need to acknowledge that effective actions for change are the products of knowledge, experience and practice. An extended epistemology in which experi- ential, practical and prepositional knowledge are equally valued is therefore fundamental. Moreover, it opens out the possibility of using a range of social theories for analysis, thus providing a broader theoretical base which is more fruit- ful in the interpretation of experience and deliberating choices and strategies for action at critical moments in PAR. Adopting focus group methods based on an extended epistemology means that focus groups could function as an instrument for understanding of the concerns of participants as well as providing them with an arena and focus for their decisions for action.

In both conventional research and PAR, focus groups are tools for generat- ing knowledge that informs practice. However, PAR writings seldom discuss

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what kinds of knowledge have been generated or ‘how’. This has led to the impression that the transformation process is ‘taken-for-granted’, and that there is a lack of clarity over the part played by focus groups in transformation. What follows is an exploration of the transformation process through different ways of knowing generated by the use of a variety of focus group methods. Examples are drawn from the above-mentioned projects.

The knowing through encounter (experiential knowing)

In order to provide opportunities for participants to explore their perceptions on and experiences in cervical screening and breast screening, a mixture of social and market approaches to focus groups were used in Stage 1. Discussion guides were formulated with presentations of stimuli in the form of a speculum, breast models, pamphlets or videos, as well as mock demonstrations. The use of stimuli and demonstrations was not only useful in helping women to recall their screen- ing experiences and to express their attitudes and opinions about the screening service, but also offered an opportunity for dialogue between the bilingual moderators and the participants.

Women appeared to become critically aware of the problems that they faced as they recalled their past experiences and entered into a dialogue among themselves and with the researcher and co-researchers. For example, focus group participants in the WTW project became aware that their rights to informed choice had been denied through lack of information about both the procedure and the purpose of cervical screening, and as a result of the use of opportunistic screening by health professionals. The following exchange illustrates the dawning of awareness among participants through the dynamic of recalling of experiences and interactions within the group.

Co-researcher: Do you remember how you had your [cervical smear] test?

1st Woman: It was an accident that I went to the Doctor. There was a nurse who wanted to give me a check up because I was newly registered there. I think they have to keep some kind of record, don’t they?

2nd Woman: I never had any check ups. My periods became abnormal, so [I] started to have a check up every three years.

Co-researcher: Yes, many people don’t know when they begin to have smear tests regularly. The programme is offered to women between 20 to 64.

2nd Woman: Oh, so it is not just after you have a baby then.

(Extract from the Vietnamese focus group in the Woman-to-Woman project)

Chiu Transformational potential of focus group practice • 175

The above dialogue indicated that most women in our study had no knowledge of the procedure and the purpose of the cervical screening. Many participants thought that the smear test was part of a medical examination undergone when one registered with a new general practitioner, while others thought it was part of post-natal testing related to cancer of the womb.

Giving an explanation to women about smear testing using a set of smear test equipment (a speculum, a spatula and a glass-slide) during the focus group not only stimulated discussion but also raised awareness of many of the predica- ments that they face. In handling the speculum, participants in one of the focus groups set off a chain of reasoning regarding their lack of knowledge about the cervical screening programme, and began to question whether there was inequal- ity of access to information between different communities.

2nd Woman: I feel that there is not enough communication going on to make women aware of the consequences of not [having] smear test[s] regularly. Although we can find out something about the ‘test’ itself, we don’t understand why we need it, and what happens if we don’t go. [Turns to the co-researcher] Could you tell me whether they [the English] had a better health promotion campaign about this? As we don’t understand English, might we have missed this information completely?

3rd Woman: I think nowadays many women in the country are more open about these things. They would quite often discuss their problems amongst each other. I think that we need more information about women’s health.

(Extract from the Chinese group in the Woman-To-Woman project)

The goal of PAR is not only to understand the predicaments of the participants but also to bring about change by actively involving them in the formulation of solutions to address the problems identified. However, before participants can suggest how things can be improved they need to become critically aware of the problems they face. The researcher who conducts focus groups with such a pur- pose in mind should be sensitive to opportunities for raising awareness. In order to do so, the line of questioning is more Socratic rather than Platonic. Rather than gleaning information from participants, the researcher will create dialogue to induce critical thinking among participants as they recall their experiences. From this perspective, facilitating experiential knowing can be seen as a pre-condition for facilitating critical awareness.

Therefore, by integrating health education opportunities into a focus group discussion and the facilitation of critical dialogue between the researcher and participants, the focus group’s function was expanded from a tool for exploring perceptions and experiences, to a tool for raising critical awareness.

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Knowing about (propositional knowing)

However, not all experiential knowing leads to critical awareness. Another kind of knowing may need to come into play before critical awareness can be devel- oped among participants. In PAR, propositional knowing is not generated by the researcher in the form of a report at the end of the project only to satisfy the funder. As Heron (1992) has suggested, ‘new conceptual understanding is formed to guide action through cycling between different kinds of knowing, and action in turn gives rise to new experiential possibility’. The interplay of propositional knowing with experiential knowing is therefore necessary for shaping new con- sciousness.

For example, the professionals in the WTW project participated in focus groups to explore their own perceptions of the reasons for low uptake of cervical screening among minority ethnic women and to identify barriers and to put for- ward suggestions as to how the identified problems could be solved. It was found that in the discussion, cultural ideology or stereotyping (Scollon & Wong Scollon, 1997) played an important part in influencing the perceptions of professionals who readily drew upon their experiential knowledge of minority ethnic women through day-to-day clinical practice to explain the low uptake of cervical screening by minority ethnic women. I witnessed the process of stereotype construction of minority ethnic women through the professionals’ narrative. It began with the polarization of minority ethnic women into ‘westernized’ and ‘non-westernized’ groups; positive attributes were then assigned to the ‘westernized’ category and negative to the ‘non-westernized’ (i.e. non-English speaking Asian women). Individual behaviours of the ‘non-westernized’ women (i.e. time-keeping habit, docility, silence, fear of physical exposure), as experienced by professionals were then generalized to all members of the cultural group (Chiu, Heywood, Jordon, Mckinney, & Dowell, 1999). The narrative was then further supported by evalua- tive comments by others in the group. The following dialogue is an example of this.

1st professional: . . . To be quite honest, you[’ve] got to be really versatile, aren’t you? Because, they don’t keep appointments always. And they come in the wrong date and they want one yesterday. That is how their system, and that is how their mind set is . . .

2nd professional: . . . It is very difficult to get them to stick to the time they have allo- cated. It’s the day or the session as such they come for.

1st professional: They don’t work on the system. They won’t and when I said won’t, I don’t mean necessarily they’re difficult. Their culture is that you can’t see any point in preventative medicine. They don’t deal with preventative medicine. And or any preventative measures. That isn’t how they see it. And the other thing is, that time matters very little. [All nodded]

(Extract from professionals’ group in the Woman-To-Woman project)

Chiu Transformational potential of focus group practice • 177

Therefore, far from being an instrument for emancipation, this particular focus group was functioning as a process in which negative stereotypes of minority ethnic women were actively constructed. This example demonstrates that the result of using focus groups as a vehicle for critical awareness-raising is not guaranteed, particularly in the ‘one-off’ settings that are common in conventional focus group practice. PAR researchers need to be aware of the dilemmas facing them in situations such as that described above. In this instance, I was confronted with the choice either to challenge such prejudices and thus risk terminating the focus group and possibly the project; or to keep the conversation going and risk my silence being taken as an encouragement by participants; and perhaps being seen, by future critics of the research, to be laying a trap for the professionals.

However, unlike conventional focus groups where participants are seldom involved beyond initial discussions (Meyer, 2000), PAR participants are often involved in data analysis to generate solutions for change actions. This involves, as good practice, the process of returning the focus group transcripts for rectifi- cation. Aided by the researcher’s theoretical understanding (propositional know- ing), participants are then involved in collective reflection on issues identified. In the WTW project, guided by the researcher’s theoretical knowledge of gender, sexuality and culture, professionals were enabled to critically reflect on their own narrative and thus began to recognize that their own attitudes and prejudices had played a powerful role in perpetuating the problem of access to cervical screening among the minority ethnic women that they served. As a result, the professionals themselves identified the required changes in their practice and committed to a course of critical learning in Stage 2 (Chiu, 1998).

Returning the transcripts to participants in PAR seems to have served a preparatory function for raising awareness. Rather than being challenged on the spot, participants were allowed to confront their own prejudice through hearing their own voices in a non-threatening way. The transcript as a collective product owned by the group, rather than as ‘data’ primarily belonging to the researcher, turned out to be a useful tool in supporting critical reflection and facilitating critical awareness. Furthermore, the content of the focus group analysis also pro- vided the framework for the critical workshops in Stage 2. This experience high- lights the complexity involved in the process of facilitating critical awareness. It is doubtful that focus groups can become a transformational tool in the context of the more prescribed object-and-subject research relationships commonly found in conventional settings.

Knowing how to do something (practical knowing)

It is important to acknowledge that much of the critical learning activities (for example, learning workshops for CHEs and professionals) happened outside the

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focus groups. However, focus groups are arguably vital in providing a structure and systematic way in which the form and content of learning can be formulated collectively.

Sometimes, focus groups functioned as milestones where participants could take stock of what they had achieved. They were also adopted to provide a regu- lar supportive mechanism for collective problem-solving in the fieldwork in Stage 3. The systematic facilitation of exploring issues arising from the implementation of the health promotion programme helped the participants to address these issues collectively and make progress in the project. For example, during the field- work period, one of the problems that arose was the difficulty the CHEs found in forming effective partnerships with professionals. On occasion they had even experienced overt hostility from some professionals when supporting women in clinical situations. This issue was brought to the focus groups. The concern that clinicians did not recognize the value of CHEs’ role and their feeling of being treated as an unequal partner in the helping process were articulated. Practical solutions were found to redress the underlying power imbalance between CHEs and professionals: first, by dealing structurally with the organization so as to legitimatize CHEs’ status in which a blanket official communication to all general practices informing practice staff of the role of the CHEs, and an official badge for CHEs were issued; second, by giving additional training in assertiveness and advocacy skills to CHEs to enhance their capacity to negotiate a more equal relationship with health professionals in clinical interactions.

Presentational knowing

Focus group processes adopted in PAR can provide opportunities for participants to join in activities through forms of communication other than writing. This is particularly useful for involving participants whose literacy level is low and among whom the primary forms of communication are oral and visual (e.g. Rudd & Comings, 1994; Wang & Burris, 1994). In all three projects described here, members of communities were specifically involved through the CHEs in the pro- duction of their own health education materials and information about cancer and the screening services. Focus group methods, particularly those developed in market research, were used in collecting designs and producing ideas for photo- stories, in which participants themselves took part in the portrayal of the screen- ing services as they experienced them. The focus groups conducted for this purpose had the function of consolidating participants’ experiential knowing-in- action. However indirectly, through the dynamic of knowing and doing in the production process, presentational knowing among participants emerged. For example, in the ST Project, we staged the shooting of the procedure for mam- mography (X-rays of breasts). Although women volunteers knew that it was all a

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stage-act, they were extremely nervous and uncomfortable, particularly when professionals inadvertently ignored cultural codes of modesty. Through this experience, both health professionals and CHEs came to recognize the important role of attending to the cultural mores of the client in allaying anxiety and fear during the procedure. The knowledge gained from this experience was articulat- ed in focus groups that followed, and subsequently incorporated into the training materials for professionals.

Heron’s (1981, 1992) extended epistemology is grounded in experiences and these experiences can be expressed through different representations. The above examples demonstrate that maximizing the potential of focus groups as a tool for transformation requires an epistemological position that embodies the dynamic moments of knowing and doing, knowledge and action.

Conclusion

Concerns over low uptakes of cancer screening among minority ethnic women have spurred much research and practical activity to address the problem. How- ever, conventional research methods yield contradictory results and the under- standing of the phenomenon produced by these methods has been inadequate to inform health promotion practice. Over the past decade I have conducted three participatory action research projects in succession to address this issue. In all of these projects, focus group methods were used as a vehicle for participation and empowerment with the goal of transforming health promotion practice.

In the light of this experience, this article explores the transformational potential of focus groups. It is suggested that if we accept the extended epistemo- logical framework as the basis for the creation of knowledge, we are then enabled to ground our focus group practice upon the dynamic process of knowing and doing. Focus groups, as practiced in PAR, will not be a prescribed activity con- forming to rules of one discipline or another. I have drawn on particular exam- ples from my research projects to illustrate the dialectical process of knowing and doing embedded in PAR and to show how it can be facilitated through focus group activities structured in a three-stage research framework. These examples demonstrate that a variety of focus group methods can be adapted not only to facilitate critical awareness-raising, but also as a systematic and focused way of managing the change process through problem-solving, decision-making and reflection.

However, the claim to transformation in PAR, particularly when commu- nicating such a claim to a wider research community, cannot be based solely on the use of specific methods (e.g. focus groups). It requires the critical reflection of the researcher on all levels of knowing and doing (Chiu, 2002c), and the critical description of the experiences of specific struggles fought by participants who

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wield other forms of power besides talk. The precise outcomes as illustrated in the above examples cannot be specified in advance. Results are always contingent upon the dynamics of different ways of knowing and doing as organized through a whole range of experiences of which focus groups are a part. Therefore, direct claims to transformation based solely on the use of focus groups are extravagant. A coherent and sustainable claim for the transformational potential of focus groups requires us to go beyond traditional paradigmatic boundaries, to articu- late clearly the relationship between epistemology and methodology. Above all, it requires us to be both reflective and reflexive in our practice. From this perspec- tive, focus group practice can then be developed as a distinct group process that has the potential to promote change.

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Lai Fong Marguerita Chiu (BA(Hons), MSc, CAES, PhD) has a background in public health/promotion and health service management and is the developer of the Community Health Educator Model in the U.K. Human development is her main interest. Address: Nuffield Institute for Health, University of Leeds, 71–75 Clarendon Road, Leeds LS2 9PL. [Email: [email protected]]

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