Focus Groups

Anita Gibbs Dr Anita Gibbs is a Research Officer at the Probation Studies Unit, Centre for Criminological Research, Oxford University. She is currently working on a number of evaluation projects for probation services across the country. Her main research interests include relationships and partnerships between statutory and voluntary organisations, and effective social work practice. This article arises out of a review of focus group methodology conducted for the Department of Social Medicine at Bristol University in March 1997.
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Focus group research involves organised discussion with a selected group of individuals to gain information about their views and experiences of a topic. Focus group interviewing is particularly suited for obtaining several perspectives about the same topic. The benefits of focus group research include gaining insights into peoples shared understandings of everyday life and the ways in which individuals are influenced by others in a group situation. Problems arise when attempting to identify the individual view from the group view, as well as in the practical arrangements for conducting focus groups. The role of the moderator is very significant. Good levels of group leadership and interpersonal skill are required to moderate a group successfully.

Focus groups are under-used in social research, although they have a long history in market
What are focus groups?

research (Morgan 1988), and more recently in medical research (Powell & Single 1996). This Update examines the value of focus groups as a tool for social researchers and considers their potential and their limitations.

There are many definitions of a focus group in the literature, but features like organised discussion (Kitzinger 1994), collective activity (Powell et al 1996), social events (Goss & Leinbach 1996) and interaction (Kitzinger 1995) identify the contribution that focus groups make to social research. Powell et al define a focus group as a group of individuals selected and assembled by researchers to discuss and comment on, from personal experience, the topic that is the subject of the research. (1996: 499) Focus groups are a form of group interviewing but it is important to distinguish between the two. Group interviewing involves interviewing a number of people at the same time, the emphasis being on questions and responses between the researcher and participants. Focus groups however rely on

interaction within the group based on topics that are supplied by the researcher. (Morgan 1997: 12) Hence the key characteristic which distinguishes focus groups is the insight and data produced by the interaction between participants. Merton and Kendalls (1946) influential article on the focused interview set the parameters for focus group development. This was in terms of ensuring that participants have a specific experience of or opinion about the topic under investigation; that an explicit interview guide is used; and that the subjective experiences of participants are explored in relation to predetermined research questions.

Why use focus groups and not other methods?

The main purpose of focus group research is to draw upon respondents attitudes, feelings, beliefs, experiences and reactions in a way in which would not be feasible using other methods, for example observation, one-to-one interviewing, or questionnaire surveys. These attitudes, feelings and beliefs may be partially independent of a group or its social setting, but are more likely to be revealed via the social gathering and the interaction which being in a focus group entails. Compared to individual interviews, which aim to obtain individual attitudes, beliefs and feelings, focus groups elicit a multiplicity of views and emotional processes within a group context. The individual interview is easier for the researcher to control than a focus group in which participants may take the initiative. Compared to observation, a focus group enables the researcher to gain a larger amount of information in a shorter period of time. Observational methods tend to depend on waiting for things to happen, whereas the researcher follows an interview guide in a focus group. In this sense focus groups are not natural but organised events. Focus groups are particularly useful when there are power differences between the participants and decision-makers or professionals, when the everyday use of language and culture of particular groups is of interest, and when one wants to explore the degree of consensus on a given topic (Morgan & Kreuger 1993).

The role of focus groups

Focus groups can be used at the preliminary or exploratory stages of a study (Kreuger 1988); during a study, perhaps to evaluate or develop a particular programme of activities (Race et al 1994); or after a programme has been completed, to assess its impact or to generate further avenues of research. They can be used either as a method in their own right or as a complement to other methods, especially for triangulation (Morgan 1988) and validity checking. Focus groups can help to explore or generate hypotheses (Powell & Single 1996) and develop questions or concepts for questionnaires and interview guides (Hoppe et al 1995; Lankshear 1993). They are however limited in terms of their ability to generalise findings to a whole population, mainly because of the small numbers of people participating and the likelihood that the participants will not be a representative sample. Examples of research in which focus groups have been employed include developing HIV education in Zimbabwe (Munodawafa et al 1995),

understanding how media messages are processed (Kitzinger 1994 & 1995), exploring peoples fear of woodlands (Burgess 1996) and distance interviewing of family doctors (White & Thomson 1995).

Potential and limitations

Kitzinger (1994, 1995) argues that interaction is the crucial feature of focus groups because the interaction between participants highlights their view of the world, the language they use about an issue and their values and beliefs about a situation. Interaction also enables participants to ask questions of each other, as well as to re-evaluate and reconsider their own understandings of their specific experiences. Another benefit is that focus groups elicit information in a way which allows researchers to find out why an issue is salient, as well as what is salient about it (Morgan 1988). As a result, the gap between what people say and what they do can be better understood (Lankshear 1993). If multiple understandings and meanings are revealed by participants, multiple explanations of their behaviour and attitudes will be more readily articulated. The benefits to participants of focus group research should not be underestimated. The opportunity to be involved in decision making processes (Race et al 1994), to be valued as experts, and to be given the chance to work collaboratively with researchers (Goss & Leinbach 1996) can be empowering for many participants. If a group works well, trust develops and the group may explore solutions to a particular problem as a unit (Kitzinger 1995), rather than as individuals. Not everyone will experience these benefits, as focus groups can also be intimidating at times, especially for inarticulate or shy members. Hence focus groups are not empowering for all participants and other methods may offer more opportunities for participants. However if participants are actively involved in something which they feel will make a difference, and focus group research is often of an applied nature, empowerment can realistically be achieved. Another advantage of focus groups to clients, users, participants or consumers is that they can become a forum for change (Race et al 1994), both during the focus group meeting itself and afterwards. For example, in research conducted by Goss & Leinbach (1996), the participants in the research experienced a sense of emancipation through speaking in public and by developing reciprocal relationships with the researchers. In another study (Smith et al 1995), patients in hospital were invited to give their views about services and to provide ideas about improvements. In this instance change occurred at the management level as a direct result of patients input. Although focus group research has many advantages, as with all research methods there are limitations. Some can be overcome by careful planning and moderating, but others are unavoidable and peculiar to this approach. The researcher, or moderator, for example, has less control over the data produced (Morgan 1988) than in either quantitative studies or one-to-one interviewing. The moderator has to allow participants to talk to each other, ask questions and express doubts and opinions, while having very little control over the interaction other than

generally keeping participants focused on the topic. By its nature focus group research is open ended and cannot be entirely predetermined. It should not be assumed that the individuals in a focus group are expressing their own definitive individual view. They are speaking in a specific context, within a specific culture, and so sometimes it may be difficult for the researcher to clearly identify an individual message. This too is a potential limitation of focus groups. On a practical note, focus groups can be difficult to assemble. It may not be easy to get a representative sample and focus groups may discourage certain people from participating, for example those who are not very articulate or confident, and those who have communication problems or special needs. The method of focus group discussion may also discourage some people from trusting others with sensitive or personal information. In such cases personal interviews or the use of workbooks alongside focus groups may be a more suitable approach. Finally, focus groups are not fully confidential or anonymous, because the material is shared with the others in the group.

The practical organisation of focus groups

Organising focus group interviews usually requires more planning than other types of interviewing as getting people to group gatherings can be difficult and setting up appropriate venues with adequate recording facilities requires a lot of time. The recommended number of people per group is usually six to ten (MacIntosh 1993), but some researchers have used up to fifteen people (Goss & Leinbach 1996) or as few as four (Kitzinger 1995). Numbers of groups vary, some studies using only one meeting with each of several focus groups (Burgess 1996), others meeting the same group several times. Focus group sessions usually last from one to two hours. Neutral locations can be helpful for avoiding either negative or positive associations with a particular site or building (Powell & Single 1996). Otherwise the focus group meetings can be held in a variety of places, for example, peoples homes, in rented facilities, or where the participants hold their regular meetings if they are a pre-existing group. It is not always easy to identify the most appropriate participants for a focus group. If a group is too heterogeneous, whether in terms of gender or class, or in terms of professional and lay perspectives, the differences between participants can make a considerable impact on their contributions. Alternatively, if a group is homogenous with regard to specific characteristics, diverse opinions and experiences may not be revealed. Participants need to feel comfortable with each other. Meeting with others whom they think of as possessing similar characteristics or levels of understanding about a given topic, will be more appealing than meeting with those who are perceived to be different (Morgan 1988). Once the types of participant have been decided, locating them is the next challenge. Recruitment of participants can be time consuming, especially if the topic under consideration has no immediate benefits or attractions to participants. It is likely that people with specific interests will have to be recruited by word of mouth (Burgess 1996), through the use of key informants, by advertising or poster campaigns (Holbrook & Jackson 1996), or through existing

social networks. Incentives, whether expenses, gift vouchers or presents, will usually need to be offered.

The role of moderator

Once a meeting has been arranged, the role of moderator or group facilitator becomes critical, especially in terms of providing clear explanations of the purpose of the group, helping people feel at ease, and facilitating interaction between group members. During the meeting moderators will need to promote debate, perhaps by asking open questions. They may also need to challenge participants, especially to draw out peoples differences, and tease out a diverse range of meanings on the topic under discussion. Sometimes moderators will need to probe for details, or move things forward when the conversation is drifting or has reached a minor conclusion. Moderators also have to keep the session focused and so sometimes they may deliberately have to steer the conversation back on course. Moderators also have to ensure everyone participates and gets a chance to speak. At the same time moderators are encouraged not to show too much approval (Kreuger 1988), so as to avoid favouring particular participants. They must avoid giving personal opinions so as not to influence participants towards any particular position or opinion. The role of the moderator is a demanding and challenging one, and moderators will need to possess good interpersonal skills and personal qualities, being good listeners, non-judgmental and adaptable. These qualities will promote the participants trust in the moderator and increase the likelihood of open, interactive dialogue. Finally, the degree of control and direction imposed by moderators will depend upon the goals of the research as well as on their preferred style. If two or more moderators are involved in the facilitation of a focus group, agreement needs to be reached as to how much input or direction each will give. It is recommended that one moderator facilitates and the other takes notes and checks the recording equipment during the meeting. There also needs to be consistency across focus groups, so careful preparation with regard to role and responsibilities is required.

Ethical issues
Ethical considerations for focus groups are the same as for most other methods of social research (Homan 1991). For example, when selecting and involving participants, researchers must ensure that full information about the purpose and uses of participants contributions is given. Being honest and keeping participants informed about the expectations of the group and topic, and not pressurising participants to speak is good practice. A particular ethical issue to consider in the case of focus groups is the handling of sensitive material and confidentiality given that there will always be more than one participant in the group. At the outset moderators will need to clarify that each participants contributions will be shared with the others in the group as well as with the moderator. Participants need to be encouraged to keep confidential what they hear during the meeting and researchers have the responsibility to anonymise data from the group.

Conclusion
This article has outlined the main features of focus group research, paying particular attention to the benefits of interaction and group dynamics which only this method can offer. Practical considerations and the time it takes to conduct focus group research may discourage many from attempting to collect data using this method. Nevertheless those who participate in this kind of research often find the experience rewarding. The process of research can be more collaborative than other forms of study, and so focus group research can be an empowering process for participants, and an exciting challenge for social researchers wanting to gain a different perspective on their field of interest.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background
The purpose of this article is to describe and evaluate the methodology of online focus group discussions within the setting of paediatric oncology.

Methods
Qualitative study consisting of separate moderated asynchronous online discussion groups with 7 paediatric cancer patients (aged 817), 11 parents, and 18 survivors of childhood cancer (aged 8 17 at diagnosis).

Results
All three participant groups could be actively engaged over a one-week period. Respondents highly valued the flexibility and convenience of logging in at their own time and place to join the discussion. Adolescent patients and survivors emphasized that the anonymity experienced made them feel comfortable to express their views in detail. The findings indicate a strong preference for online group discussions across all participant groups.

Conclusion
The findings show that online focus group methodology is a feasible tool for collecting qualitative data within the setting of paediatric oncology, and may offer new opportunities to collect data in other hard-to-include populations. The evaluations seem to indicate that the online group discussions have given participants an opportunity to articulate their experiences and views in a way they might not have done in a traditional group discussion.

Background
The world-wide expansion of access to and use of the Internet over the last twdecades has made the Web a prominent mode of communication, permeating people's personal and professional lives. More recently, the Internet is being recognized as a research tool, offering new opportunities for researchers to conduct quantitative and qualitative research. Gaining popularity first in marketing research, and in communication and media studies, Internet-based data collection is receiving increasing attention in the social and health sciences. [1-8] In particular, the Web offers the unique possibility to include participants who are hard to reach using traditional research methods, e.g. due to time constraints, immobility, or active treatment. [7,916] Interest in online focus groups came at a time when researchers were being assailed by recruitment problems, declining response rates, and rapidly raising costs for traditional focus group discussions. Independent of the setting, patient recruitment often is a bottle-neck in research and a considerable number of projects need much more time than planned to obtain a significant number of patients. [17] In this paper, we intend to contribute to this discussion by describing the methods and feasibility of online focus group discussions within the setting of paediatric oncology.

New modes of focus groups

A traditional face-to-face focus group (TFG) discussion is a form of group interview, which has been a well-established practice for data collection across a range of disciplines since the early

part of the 20th century [18-20]. The method is particularly effective for exploring people's opinions and experiences regarding illness and healthcare, both from a consumers' and a providers' perspective. [15,21-23] The appropriateness of this research tool in eliciting children's views on and experiences in health-related matters has been shown extensively [24-28]. Distinctive terminology may be used for denoting online focus group (OFG) discussions: e.g. computer-mediated or Internet-based focus groups, electronic focus groups, chat-based focus groups, or virtual panel discussions. [1,11,15,29-37] All labels refer to research methods that utilize the Internet to unite spatially and possibly temporally separate participants in text-based group discussions, guided by a moderator. In general, the term OFG does not refer to chat rooms or open panel discussions where participants are free to log in at any time, and post their comments on a random topic. OFGs can be conducted in two ways: synchronously (in real time) or asynchronously (not in real time), or using a combination of both. In the synchronous mode, participants are online simultaneously at a prearranged time, and immediately react to each other's responses as these are received. The asynchronous mode refers to an ongoing website where participants are free to log in during a set period, read each others' contributions and post a comment themselves at a time that is convenient for them, not necessarily when anyone else is participating.

Benefits online focus groups

Recent studies on the potential benefits of the use of OFGs were remarkably similar, drawing particular attention to: recruitment issues, participant convenience, researcher benefits, and the quality of the data obtained. The most obvious advantage of using online focus group methodology is that it enables access to populations that are hard to include using standard research techniques and that it facilitates dialogue between participants who may not otherwise have spoken with each other [8,9,11,13,16,30,32,38]. The Internet allows new recruitment opportunities for ill or disabled participants, housebound respondents, marginalized populations, and socially or geographically isolated people. Recruitment is a problem associated with TFG

and is likely to grow, because of the increasing difficulty of scheduling meetings for busy people. The use of OFG may be an important tool used to circumvent this problem. A second significant advantage of using OFGs is providing participants a convenient and comfortable way of joining group discussions. [1,3,6,11,14,16,33,39] Unconstrained by place and time, online participants can contribute to the group discussion at their leisure and individual places. A distinctive feature in asynchronous group discussions is that it allows participants to choose their time in answering questions, allowing more time to reflect. In addition to these advantages for participants, potential researcher benefits have been documented as well. Foremost amongst these advantages of OFGs, are cost and time-savings due to the automatic and accurate capture of the discussion data. [4,6,9,11,12,35] Responses can be transferred directly in a database where they are immediately accessible for analysis, without the need for transcription or editing, enhancing the accuracy of collected data and eliminating transcriber bias. Additional benefits of OFGs include lower recruitment costs compared with TFGs and the absence of logistic and travel expenses.

Quality of data obtained

Several studies have investigated the comparability of findings gained from TFGs and OFGs. They seem to suggest that the quantity and quality of data obtained online are broadly comparable to those obtained by traditional focus group discussions. [15,33,34,37,39] Online data collection has the added advantage of providing an effective format to collect sensitive or personal health information. Self-disclosure, defined as 'revealing personal information to others', is a key objective in focus groups, and lack of self-disclosure is often listed as a barrier to effective group discussions. The anonymity afforded by online communication is central in the explanation of increased levels of self-disclosure in OFGs. The perceived privacy makes the online environment more conducive to eliciting honest and thoughtful responses. [30,39-43] Furthermore, the visual anonymity provided by online focus groups may reduce the social desirability bias, allowing participants to feel more comfortable to voice their viewpoints. [5,9,40,43] In traditional focus group discussions, participants may feel silenced or intimidated

by more talkative participants. An important advantage of the online mode is the greater equality in participation than in traditional groups, providing a more balanced impression of all the viewpoints being expressed in the discussion. [6,9,33,43] Finally, the absence of time-pressure in asynchronous forms of online discussion, allows considered responses that are lengthier and more detailed than those in synchronous or traditional forms [5,40,43]. The aforementioned advantages attributed to conducting group discussions online enhance the accuracy and objectivity of the data obtained, and, consequently, the quality of the data.

Examples from paediatric oncology

Guidelines in paediatric oncology encourage health providers to share developmentally relevant medical information with young patients and their parents to enable active participation in the decision-making process. [44,45] Unknown, so far, is to what extent this mirrors patients' and parents' preferences. In view of the merits of OFGs as described above, and the awareness that young patients and their parents are hard to include in group discussions, we expected the online mode of focus group discussions the best choice for this population. Children's familiarity with the Internet further pleads in favour of collecting data online. [3,14,16,46,47] So far, the use of online focus groups for collecting research data has not been explored extensively in paediatric health care. [14,16] We therefore conducted a series of asynchronous online focus group discussions with children in active treatment for paediatric cancer, their parents, and child survivors of paediatric cancer separately, to determine what constitutes good quality of communication in terms of participation and role delineation from their point of view. The descriptive results of these OFGs have been reported in more detail elsewhere. [48] In this paper, will describe the process of conducting asynchronous online focus groups within the setting of paediatric cancer care and focus on participants' evaluations of joining these group discussions online.

Methods

Sampling and recruitment

We identified a sample of three separate groups of participants: 817 year old patients in active treatment for childhood cancer (diagnosed 6 weeks to 1 year ago); parents of these children; and a group survivors of childhood cancer, who had been 8 to 17 years old at time of diagnosis, and whose treatment had been successfully finished during the preceding five years. Exclusion criteria were insufficient mastery of the Dutch language, a lag in development, treatment for secondary tumours, and being in the palliative phase of treatment (oncologists' evaluations). To minimize selection bias, patients and their parents were included by consecutive inclusion, based on order of appointment in two Dutch university paediatric oncology wards. Letters describing the study objectives and requesting participation were given to eligible families by their health care provider, either personal or by regular mail. Family members could participate on an individual basis, meaning that not necessarily both parents and child of each participating family were included. Because survivors did not visit the oncological wards on a regular basis, eligible participants were selected from electronic recording systems in both wards, and invited by regular mail. Written consent was obtained from 13 (41.9%) of the 31 eligible families, and 8 of them (25.8%) actually participated (7 patients and 11 parents). Nineteen (33.9%) out of the 56 approached survivors agreed to participate, and 18 (32.1%) actually did. Separate group discussions were organised for child patients (aged 8 to 11 years), adolescent patients (aged 12 to 17 years), parents and survivors. A letter containing background information, the homepage URL, an individual login name and password was sent to all respondents who consented to participate. For characteristics of participating patients, parents and survivors: see Table 1. Ethical approval for the study was obtained in advance (METc UMCG 2005-050 and METc UMC St Radboud AMO 05/074). Table 1. Characteristics of participants of online focus groups

Procedures
We opted for moderated, asynchronous online focus group discussions, conducted following recently developed guidelines for online data collection. [1,4-6,30,31,35,49] Precautions were taken to guarantee both the anonymity of the participants and the confidentiality of their contributions to the online discussions. Each participant was given a unique login name and password, with which they could anonymously access their discussion group website during one week, 24 hours a day. All participants were able to view the most recent contributions in their group as well as scroll back to view earlier responses. The only persons who could be identified by name were two researchers (KT and MZ) who acted as moderators. Their role in establishing a creative, synergistic, non-inhibiting environment for discussion online was very similar to what it would have beeen in a TFG, by regularly checking the postings, asking additional questions to clarify participants' views, and encouraging group discussion. [5,6,30,31] Following conventions used in TFGs, a topic guide was developed, questioning participants' experiences, needs and preferences with respect to communication in paediatric oncology. Instead of introducing all questions at the start of the OFGs, the researchers posted one question a day, aiming at optimal group discussion as recommended in previous research [32,35]. The content of the basic questions posed during the first five days was equivalent for the three groups of participants, with the wording being adapted to the age range of the respondents. On the third day, a reminder was sent to those respondents who had not been joining the discussion. During the last two days, the participants were invited to introduce new topics for discussion they considered relevant in communication in paediatric oncology. Questions of the previous days remained open for responses during the whole week. Since this was a novel technique, after closing of the OFGs, all participants were invited by email to individually evaluate the process of joining this group discussion online, using a brief semi-structured online questionnaire. Areas of evaluation were drawn from the literature on the benefits and challenges of online discussions, including questions regarding: choices between OFG and TFG, perceived benefits of both modes of group discussions, ease of access, duration of the OFGs, and whether or not to introduce all questions at the start of the discussion.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background
The purpose of this article is to describe and evaluate the methodology of online focus group discussions within the setting of paediatric oncology.

Methods
Qualitative study consisting of separate moderated asynchronous online discussion groups with 7 paediatric cancer patients (aged 817), 11 parents, and 18 survivors of childhood cancer (aged 8 17 at diagnosis).

Results
All three participant groups could be actively engaged over a one-week period. Respondents highly valued the flexibility and convenience of logging in at their own time and place to join the discussion. Adolescent patients and survivors emphasized that the anonymity experienced made them feel comfortable to express their views in detail. The findings indicate a strong preference for online group discussions across all participant groups.

Conclusion
The findings show that online focus group methodology is a feasible tool for collecting qualitative data within the setting of paediatric oncology, and may offer new opportunities to collect data in other hard-to-include populations. The evaluations seem to indicate that the online group discussions have given participants an opportunity to articulate their experiences and views in a way they might not have done in a traditional group discussion.

Background

The world-wide expansion of access to and use of the Internet over the last twdecades has made the Web a prominent mode of communication, permeating people's personal and professional lives. More recently, the Internet is being recognized as a research tool, offering new opportunities for researchers to conduct quantitative and qualitative research. Gaining popularity first in marketing research, and in communication and media studies, Internet-based data collection is receiving increasing attention in the social and health sciences. [1-8] In particular, the Web offers the unique possibility to include participants who are hard to reach using traditional research methods, e.g. due to time constraints, immobility, or active treatment. [7,916] Interest in online focus groups came at a time when researchers were being assailed by recruitment problems, declining response rates, and rapidly raising costs for traditional focus group discussions. Independent of the setting, patient recruitment often is a bottle-neck in research and a considerable number of projects need much more time than planned to obtain a significant number of patients. [17] In this paper, we intend to contribute to this discussion by describing the methods and feasibility of online focus group discussions within the setting of paediatric oncology.

New modes of focus groups

A traditional face-to-face focus group (TFG) discussion is a form of group interview, which has been a well-established practice for data collection across a range of disciplines since the early part of the 20th century [18-20]. The method is particularly effective for exploring people's opinions and experiences regarding illness and healthcare, both from a consumers' and a providers' perspective. [15,21-23] The appropriateness of this research tool in eliciting children's views on and experiences in health-related matters has been shown extensively [24-28]. Distinctive terminology may be used for denoting online focus group (OFG) discussions: e.g. computer-mediated or Internet-based focus groups, electronic focus groups, chat-based focus groups, or virtual panel discussions. [1,11,15,29-37] All labels refer to research methods that utilize the Internet to unite spatially and possibly temporally separate participants in text-based

group discussions, guided by a moderator. In general, the term OFG does not refer to chat rooms or open panel discussions where participants are free to log in at any time, and post their comments on a random topic. OFGs can be conducted in two ways: synchronously (in real time) or asynchronously (not in real time), or using a combination of both. In the synchronous mode, participants are online simultaneously at a prearranged time, and immediately react to each other's responses as these are received. The asynchronous mode refers to an ongoing website where participants are free to log in during a set period, read each others' contributions and post a comment themselves at a time that is convenient for them, not necessarily when anyone else is participating.

Benefits online focus groups

Recent studies on the potential benefits of the use of OFGs were remarkably similar, drawing particular attention to: recruitment issues, participant convenience, researcher benefits, and the quality of the data obtained. The most obvious advantage of using online focus group methodology is that it enables access to populations that are hard to include using standard research techniques and that it facilitates dialogue between participants who may not otherwise have spoken with each other [8,9,11,13,16,30,32,38]. The Internet allows new recruitment opportunities for ill or disabled participants, housebound respondents, marginalized populations, and socially or geographically isolated people. Recruitment is a problem associated with TFG and is likely to grow, because of the increasing difficulty of scheduling meetings for busy people. The use of OFG may be an important tool used to circumvent this problem. A second significant advantage of using OFGs is providing participants a convenient and comfortable way of joining group discussions. [1,3,6,11,14,16,33,39] Unconstrained by place and time, online participants can contribute to the group discussion at their leisure and individual places. A distinctive feature in asynchronous group discussions is that it allows participants to choose their time in answering questions, allowing more time to reflect.

In addition to these advantages for participants, potential researcher benefits have been documented as well. Foremost amongst these advantages of OFGs, are cost and time-savings due to the automatic and accurate capture of the discussion data. [4,6,9,11,12,35] Responses can be transferred directly in a database where they are immediately accessible for analysis, without the need for transcription or editing, enhancing the accuracy of collected data and eliminating transcriber bias. Additional benefits of OFGs include lower recruitment costs compared with TFGs and the absence of logistic and travel expenses.

Quality of data obtained

Several studies have investigated the comparability of findings gained from TFGs and OFGs. They seem to suggest that the quantity and quality of data obtained online are broadly comparable to those obtained by traditional focus group discussions. [15,33,34,37,39] Online data collection has the added advantage of providing an effective format to collect sensitive or personal health information. Self-disclosure, defined as 'revealing personal information to others', is a key objective in focus groups, and lack of self-disclosure is often listed as a barrier to effective group discussions. The anonymity afforded by online communication is central in the explanation of increased levels of self-disclosure in OFGs. The perceived privacy makes the online environment more conducive to eliciting honest and thoughtful responses. [30,39-43] Furthermore, the visual anonymity provided by online focus groups may reduce the social desirability bias, allowing participants to feel more comfortable to voice their viewpoints. [5,9,40,43] In traditional focus group discussions, participants may feel silenced or intimidated by more talkative participants. An important advantage of the online mode is the greater equality in participation than in traditional groups, providing a more balanced impression of all the viewpoints being expressed in the discussion. [6,9,33,43] Finally, the absence of time-pressure in asynchronous forms of online discussion, allows considered responses that are lengthier and more detailed than those in synchronous or traditional forms [5,40,43]. The aforementioned advantages attributed to conducting group discussions online enhance the accuracy and objectivity of the data obtained, and, consequently, the quality of the data.

Examples from paediatric oncology

Guidelines in paediatric oncology encourage health providers to share developmentally relevant medical information with young patients and their parents to enable active participation in the decision-making process. [44,45] Unknown, so far, is to what extent this mirrors patients' and parents' preferences. In view of the merits of OFGs as described above, and the awareness that young patients and their parents are hard to include in group discussions, we expected the online mode of focus group discussions the best choice for this population. Children's familiarity with the Internet further pleads in favour of collecting data online. [3,14,16,46,47] So far, the use of online focus groups for collecting research data has not been explored extensively in paediatric health care. [14,16] We therefore conducted a series of asynchronous online focus group discussions with children in active treatment for paediatric cancer, their parents, and child survivors of paediatric cancer separately, to determine what constitutes good quality of communication in terms of participation and role delineation from their point of view. The descriptive results of these OFGs have been reported in more detail elsewhere. [48] In this paper, will describe the process of conducting asynchronous online focus groups within the setting of paediatric cancer care and focus on participants' evaluations of joining these group discussions online.

Methods

Sampling and recruitment

We identified a sample of three separate groups of participants: 817 year old patients in active treatment for childhood cancer (diagnosed 6 weeks to 1 year ago); parents of these children; and a group survivors of childhood cancer, who had been 8 to 17 years old at time of diagnosis, and whose treatment had been successfully finished during the preceding five years. Exclusion criteria were insufficient mastery of the Dutch language, a lag in development, treatment for secondary tumours, and being in the palliative phase of treatment (oncologists' evaluations).

To minimize selection bias, patients and their parents were included by consecutive inclusion, based on order of appointment in two Dutch university paediatric oncology wards. Letters describing the study objectives and requesting participation were given to eligible families by their health care provider, either personal or by regular mail. Family members could participate on an individual basis, meaning that not necessarily both parents and child of each participating family were included. Because survivors did not visit the oncological wards on a regular basis, eligible participants were selected from electronic recording systems in both wards, and invited by regular mail. Written consent was obtained from 13 (41.9%) of the 31 eligible families, and 8 of them (25.8%) actually participated (7 patients and 11 parents). Nineteen (33.9%) out of the 56 approached survivors agreed to participate, and 18 (32.1%) actually did. Separate group discussions were organised for child patients (aged 8 to 11 years), adolescent patients (aged 12 to 17 years), parents and survivors. A letter containing background information, the homepage URL, an individual login name and password was sent to all respondents who consented to participate. For characteristics of participating patients, parents and survivors: see Table 1. Ethical approval for the study was obtained in advance (METc UMCG 2005-050 and METc UMC St Radboud AMO 05/074). Table 1. Characteristics of participants of online focus groups

Procedures
We opted for moderated, asynchronous online focus group discussions, conducted following recently developed guidelines for online data collection. [1,4-6,30,31,35,49] Precautions were taken to guarantee both the anonymity of the participants and the confidentiality of their contributions to the online discussions. Each participant was given a unique login name and password, with which they could anonymously access their discussion group website during one week, 24 hours a day. All participants were able to view the most recent contributions in their group as well as scroll back to view earlier responses. The only persons who could be identified by name were two researchers (KT and MZ) who acted as moderators. Their role in establishing

a creative, synergistic, non-inhibiting environment for discussion online was very similar to what it would have beeen in a TFG, by regularly checking the postings, asking additional questions to clarify participants' views, and encouraging group discussion. [5,6,30,31] Following conventions used in TFGs, a topic guide was developed, questioning participants' experiences, needs and preferences with respect to communication in paediatric oncology. Instead of introducing all questions at the start of the OFGs, the researchers posted one question a day, aiming at optimal group discussion as recommended in previous research [32,35]. The content of the basic questions posed during the first five days was equivalent for the three groups of participants, with the wording being adapted to the age range of the respondents. On the third day, a reminder was sent to those respondents who had not been joining the discussion. During the last two days, the participants were invited to introduce new topics for discussion they considered relevant in communication in paediatric oncology. Questions of the previous days remained open for responses during the whole week. Since this was a novel technique, after closing of the OFGs, all participants were invited by email to individually evaluate the process of joining this group discussion online, using a brief semi-structured online questionnaire. Areas of evaluation were drawn from the literature on the benefits and challenges of online discussions, including questions regarding: choices between OFG and TFG, perceived benefits of both modes of group discussions, ease of access, duration of the OFGs, and whether or not to introduce all questions at the start of the discussion.