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

ARTICLE Transformational potential of

focus group practice in
participatory action research
Lai Fong Chiu
Nuffield Institute for Health, University of Leeds

ABSTRACT

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.

KEY WORDS

• epistemology
• focus group
practice
• transformation

165
166 • Action Research 1(1)

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
 Chiu Transformational potential of focus group practice • 167

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
168 • Action Research 1(1)

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
 Chiu Transformational potential of focus group practice • 169

Stage 1 Stage 2 Stage 3

Problem identification Solution generation Implementation and

evaluation

Focus groups for women Focus groups held for Focus groups held for
from different construction of problem solving and for
language/ethnic groups intervention programme evaluation
and for professionals

Facilitate experiential and Facilitate practical know- Facilitate critical reflection

prepositional knowing for ing and representational on change and
actions in Stage 2 knowing consolidate different
knowing(s)

Review

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

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
170 • Action Research 1(1)

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
 Chiu Transformational potential of focus group practice • 171

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
172 • Action Research 1(1)

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),
Cantonese, Gujarati, Hindi,
Punjabi (Sikh), Pakistani
(Mirpuri) and Vietnamese
(Vietnamese or Cantonese)
Arabic (Yemeni), Bengali (Sylheti),
Bengali (Sylheti), Chinese (Cantonese)
Chinese (Cantonese), and Pakistani (Mirpuri)
Pakistani (Mirpuri) and
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
 Chiu Transformational potential of focus group practice • 173

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.
174 • Action Research 1(1)

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
 Chiu Transformational potential of focus group practice • 175

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)

176 • Action Research 1(1)

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.
 Chiu Transformational potential of focus group practice • 177

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)

178 • Action Research 1(1)

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
 Chiu Transformational potential of focus group practice • 179

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
180 • Action Research 1(1)

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
 Chiu Transformational potential of focus group practice • 181

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.

References

Altrichter, H., & Gestettner, P. (1997). Action research: A closed chapter in the
history of German social science? In R. McTaggart (Ed.), Participatory action
research: International contexts and consequences (pp. 45–78). Albany: State
University of New York Press.
Basch, C. E. (1987). Focus group interview: An under-utilized research technique for
improving theory and practice in health education. Health Education Quarter-
ly, 14(4), 411–448.
Blackburn, J., & Holland, J. (1998a). Who changes? Institutionalizing participation
in development. London: Intermediate Technology Publications.
Blackburn, J., & Holland, J. (1998b). Whose voice? Participatory research and policy
change. London: Intermediate Technology Publications.
Calder, B. J. (1977). Focus groups and the nature of qualitative marketing research.
Journal of Marketing Research, 14(August), 353–364.
Chiu, L. F. (Ed.). (1993). Communicating breast screening messages to minority
women. A conference report. Leeds: Leeds Health Promotion Service.
Chiu, L. F. (1998). Woman-To-Woman: Promoting cervical screening among minor-
ity ethnic women in primary care, a participatory action research project
(1995–1997). A research report. Rotherham: Department of Health Promotion,
Rotherham Health Authority.
Chiu, L. F. (2000). A participatory action research study of an intercultural commu-
nication strategy for improving the experience of cervical screening among
minority ethnic women in the primary care setting. Unpublished PhD thesis,
University of Leeds.
Chiu, L. F. (2002a). Straight talking: Communicating breast screening information in
primary care. Leeds: Nuffield Institute for Health, University of Leeds.
Chiu, L. F. (2002b). Straight talking: Breast screening training pack. Leeds: Nuffield
Institute for Health, University of Leeds.
Chiu, L. F. (2002c). Critical reflection: More than nuts and bolts. Conference Paper
presented to the XV World Congress of Sociology, Brisbane, Australia. July,
2002.
Chiu, L. F., Heywood, P., Jordon, J., & McKinney, P., and Dowell, A. (1999).
Balancing the equation: The significance of professional and lay perceptions in
182 • Action Research 1(1)

the promotion of cervical screening among minority ethnic women. Critical

Public Health, 9(11), 5–22.
Chiu, L. F., Knight, D., & Williams, S. (1993). Breast screening training pack for
minority women. Leeds: Leeds Health Promotion Service.
Cunningham-Burley, S., Kerr, A., & Pavis, S. (1999). Theorizing subjects and subject
matter in focus group research. In R. Barbour & J. Kitzenger (Eds.), Developing
focus group research: Politics, theory and practice (186–199). London: Sage.
Doyle, Y. (1991). A survey of the cervical screening service in a London district,
including reasons for non-attendance, ethnic responses and views on the quality
of service. Social Science & Medicine, 32, 953–957.
Egwu, I. N. (1992). Application of focus group and survey methods in the study of
rural primary health care development. International Quarterly Community
Health Education, 12(4), 283–292.
Fals-Borda, O., & Rahman, M. A. (Eds.). (1991). Action and knowledge: Breaking
the monopoly with participatory action research. New York: Intermediate
Technology/Apex.
Fern, E. F. (2001). Advanced focus group research. Thousand Oaks, CA: Sage.
Greenbaum, T. L. (1993). The handbook for focus group research. New York:
Lexington Books.
Hart, E., & Bond, M. (1995). Action research for health and social care: A guide to
practice. Milton Keynes: Open University Press.
Heron, J. (1981). Philosophical basis for a new paradigm. In P. Reason & J. Rowan
(Eds.), Human inquiry: A sourcebook of new paradigm research (pp. 19–35).
Chichester: John Wiley.
Heron, J. (1992). Feeling and personhood: Psychology in another key. London: Sage.
Jepson, R., Clegg, A., Forbes, C., Lewis, R., Sowden, A., & Kleijnen, J. (2000). The
determinants of screening uptake and interventions for increasing uptake: a
systematic review. Health Technology Assessment NHS R&D HTA Pro-
gramme. Alton (on behalf of the National Coordinating Centre of Health Tech-
nology Assessment): Core Research.
Johnson, A. (1996). ‘It’s good to talk’: The focus group and the sociological imagina-
tion. The Editorial Board of The Sociological Review, 517–538.
Kitzinger, J. (1994). The methodology of focus groups: The importance of interaction
between research participants. Sociology of Health & Illness, 16, 103–121
Krueger, R. A. (1994). Focus group: A practical guide for applied research. (2nd edi-
tion.) Thousand Oaks, CA: Sage.
Lewin, K. (1946). Action research and minority problems. Journal of Social Issues, 2,
34–46.
McAvoy, B. R., & Raza, R. (1988). Asian women (1) Contraceptive knowledge, atti-
tudes and usage, (2) Contraceptive services and cervical cytology. Health
Trends, 20, 11–17.
McAvoy, B. R., & Raza, R. (1991). Can health education increase uptake of cervical
smear testing among Asian women? British Medical Journal, 302, 833–836.
Meyer, J. (2000). Qualitative methods in health-related action research. In C. Pope &
N. Mays (Eds.), Qualitative research in health care. BMJ Publication retrieved
August 2001 from http://www.bmjpg.com/qrhc/chapter7.htm
Morgan, D. L., & Krueger, R. A. (1993). When to use focus group and why. In D.
Morgan (Ed.), Successful focus groups: Advancing the state of the art (pp.
3–19). Thousand Oaks, CA: Sage.
 Chiu Transformational potential of focus group practice • 183

Naish, J., Brown, J., & Denton, B. (1994). Intercultural consultations: Investigation of
factors that deter non-English speaking women from attending their general
practitioners for cervical screening. British Medical Journal, 309, 1126–1128.
Padilla, R. (1993). Using dialogical research methods in group interviews. In D.
Morgan (Ed.), Successful focus groups: Advancing the state of the art (pp.
153–166). Thousand Oaks, CA: Sage.
Reason, P. (1993). Sitting between appreciation and disappointment: A critique of the
special edition of human relations on action research. Human Relations,
46(10), 1253–1270.
Reason, P. (1994). Three approaches to participative inquiry. In N. K. Denzin & Y. S.
Lincoln (Eds.), Handbook of qualitative research (pp. 324–338). London: Sage.
Reason, P., & Bradbury, H. (2001). Handbook of action research: Participative
inquiry and practice. London: Sage.
Rotherham Health Authority (1998). Woman-To-Woman: Cervical screening train-
ing pack for minority women. Rotherham: Rotherham Health Promotion.
Rudd, R. E., & Comings, J. P. (1994). Learner developed materials: An empowering
product. Health Education Quarterly, 21(3), 313–327.
Scollon, R., & Wong Scollon, S. (1997). Intercultural communication: A discourse
approach. Oxford: Blackwell Publisher Ltd.
Stewart, D. W., & Shamdasani, P. N. (1990). Focus groups: Theory and practice.
Thousand Oaks, CA: Sage.
Wang, C., & Burris, M. A. (1994). Empowerment through photo novella: Portraits of
participation. Health Education Quarterly, 21(2), summer, 171–186.

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: hsslfmc@hyde1.leeds.ac.uk]