focus group literature review

Literature review: considerations in undertaking focus group research with culturally and linguistically diverse groups

Affiliation.

• 1 Centre for Applied Nursing Research, University of Western Sydney and Sydney South West Area Health Service, Liverpool, NSW, Australia.
• PMID: 17518876
• DOI: 10.1111/j.1365-2702.2006.01760.x

Aims: This integrated literature review seeks to identify the key considerations in conducting focus groups and discusses the specific considerations for focus group research with culturally and linguistically diverse groups.

Background: The focus group method is a technique of group interview that generates data through the opinions expressed by participants. Focus groups have become an increasingly popular method of data collection in health care research. Although focus groups have been used extensively with Western populations, they are a particularly useful tool for engaging culturally and linguistically diverse populations. The success of focus groups in this context is dependent upon the cultural competence of the research team and the research questions.

Methods: The electronic databases Medline, CINAHL, Embase, Psychlit and the Internet using the Google Scholar search engine were explored using the search terms 'focus group', 'cultural sensitivity', 'transcultural nursing', 'transcultural care', 'cultural diversity' and 'ethnic groups'. Hand searching of reference lists and relevant journals was also undertaken. English language articles were selected for the review if they discussed the following issues: (i) methodological implications of the focus group method; (ii) strengths and limitations of the focus group method; (iii) recommendations for researchers and (iv) use of the focus group in culturally and linguistically diverse groups. Conclusions were drawn from each of the articles and consensus regarding a summary of recommendations was derived from a minimum of two authors.

Results: Findings from this review revealed several key issues involving focus group implementation including recruitment, sample size, data collection, data analysis and use within multicultural populations. Strengths and limitations of the focus group method were also identified.

Conclusions: Focus groups are a useful tool to expand existing knowledge about service provision and identify consumer needs that will assist in the development of future intervention programmes, particularly within multicultural populations. Careful planning related to methodological and pragmatic issues are critical in deriving effective data and protecting participants.

Relevance to clinical practice: Focus groups can facilitate increased understanding of perspectives of culturally and linguistically diverse groups and thereby shape clinical practice to better meet the needs of these groups.

Publication types

• Attitude to Health / ethnology
• Clinical Competence
• Communication Barriers
• Cultural Diversity*
• Data Collection
• Data Interpretation, Statistical
• Focus Groups / methods*
• Focus Groups / standards
• Group Processes
• Health Knowledge, Attitudes, Practice
• Health Services Needs and Demand
• Health Services Research / methods
• Interviews as Topic / methods
• Nursing Methodology Research / methods*
• Nursing Methodology Research / standards
• Patient Selection
• Qualitative Research
• Reproducibility of Results
• Research Design* / standards
• Research Personnel / organization & administration
• Research Personnel / psychology
• Sample Size
• Time Factors
• Transcultural Nursing

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Literature Review: Considerations In Undertaking Focus Group Research With Culturally and Linguistically Diverse Groups

2007, Journal of Clinical …

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• Published: 07 February 2023

Scoping literature review and focus groups with healthcare professionals on psychosocial and lifestyle assessments for childhood obesity care

• L. W. Koetsier 1 ,
• E. van den Eynde 1 , 2 ,
• E. G. A. H. van Mil 3 , 4 ,
• M. van der Velde 5 ,
• R. de Vries 6 ,
• C. A. Baan 7 ,
• J. C. Seidell 1 &
• J. Halberstadt 1  

BMC Health Services Research volume  23 , Article number:  125 ( 2023 ) Cite this article

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Childhood obesity is a complex disease resulting from the interaction of multiple factors. The effective management of childhood obesity requires assessing the psychosocial and lifestyle factors that may play a role in the development and maintenance of obesity. This study centers on available scientific literature on psychosocial and lifestyle assessments for childhood obesity, and experiences and views of healthcare professionals with regard to assessing psychosocial and lifestyle factors within Dutch integrated care.

Two methods were used. First, a scoping review (in PubMed, Embase, PsycInfo, IBSS, Scopus and Web of Science) was performed by systematically searching for scientific literature on psychosocial and lifestyle assessments for childhood obesity. Data were analysed by extracting data in Microsoft Excel. Second, focus group discussions were held with healthcare professionals from a variety of disciplines and domains to explore their experiences and views about assessing psychosocial and lifestyle factors within Dutch integrated care. Data were analysed using template analysis, complemented with open coding in MAXQDA.

The results provide an overview of relevant psychosocial and lifestyle factors that should be assessed and were classified as child, family, parental and lifestyle (e.g. nutrition, physical activity and sleep factors) and structured into psychological and social aspects. Insights into how to assess psychosocial and lifestyle factors were identified as well, including talking about psychosocial factors, lifestyle and weight; the professional-patient relationship; and attitudes of healthcare professionals.

Conclusions

This study provides an overview of psychosocial and lifestyle factors that should be identified within the context of childhood obesity care, as they may contribute to the development and maintenance of obesity. The results highlight the importance of both what is assessed and how it is assessed. The results of this study can be used to develop practical tools for facilitating healthcare professionals in conducting a psychosocial and lifestyle assessment.

Peer Review reports

Introduction

Urgency and complexity of childhood obesity.

In the Netherlands, in 2020, 12.2% of the children aged 4–17 years had overweight and 2.5% had obesity [ 1 ]. Childhood obesity is associated with a range of short-term and long-term physical health problems and psychosocial problems [ 2 , 3 ]. Moreover, childhood obesity is regarded as a chronic disease that tracks into adulthood [ 4 ]. It is a complex disease resulting from the interaction of multiple underlying factors, including personal characteristics (e.g. genetic, hormonal, physical and psychological) and environmental factors (e.g. socio-economic, cultural and physical environments) that can influence lifestyle behaviour and lead to the development or maintenance of childhood obesity [ 5 , 6 , 7 ]. Adequate management of childhood obesity calls for taking into account biomedical factors (e.g. genetic factors, comorbidities, extent of overweight or obesity), psychological factors (e.g. self-image, mood, well-being) and social factors (at various levels, including contact with peers, school or authorities) [ 8 , 9 ].

Context of the Dutch healthcare system

The importance of conducting an assessment of potentially interacting biomedical, psychosocial and lifestyle factors has been internationally recognised in clinical guidelines [ 10 , 11 , 12 , 13 ]. The Dutch ‘National model integrated care for childhood overweight and obesity’ describes the assessment of psychosocial and lifestyle factors, which is an essential step as part of the integrated care process. The psychosocial and lifestyle assessment is conducted by a coordinating professional (CP) [ 14 , 15 , 16 ]. The CP role can be fulfilled by various professionals from different disciplines and domains (e.g. healthcare domain, social domain). In many cases, it is fulfilled by a professional in the local youth healthcare (YHC) system [ 15 , 16 ]. The YHC system is based on a municipal or regional infrastructure in which all children 0–19 years of age receive frequent medical check-ups and referrals [ 17 ].

Assessment of psychosocial and lifestyle factors

In a previous study, we examined a supporting assessment tool that CPs can use as a guide for obtaining information about factors that may contribute to the development and maintenance of obesity and obtaining a broad view of children and their family circumstances [ 18 , 19 ]. In that study, we also identified several potential improvements to be made in the further development of the tool, including the addition of in-depth questions for assessing psychosocial factors, the inclusion of an instructional guide explaining how to use the assessment tool and the adaptation of the tool to make it more age-specific [ 19 ]. In addition, the CPs who were interviewed for that study expressed a need for more knowledge about the complexity of obesity and the development of age-appropriate visual materials for conducting psychosocial and lifestyle assessments [ 19 ]. Because the study was conducted amongst only fourteen CPs, broader insight is needed with regard to the experiences and views of healthcare professionals (HCPs) from a variety of disciplines and domains with assessing psychosocial and lifestyle factors within the integrated care. Such insights could help to optimise the tool and to assist HCPs in the provision of personalised childhood obesity care.

Aim of the study

The combination of the designated CP role, the conduction of the psychosocial and lifestyle assessment, mentioned required improvements based on an earlier study and a need from practice for more knowledge and materials makes this study necessary as broader insight is needed [ 19 ].

Therefore, the aim of this study is to investigate available literature on psychosocial and lifestyle assessments for childhood obesity and experiences and views of HCPs with regard to assessing psychosocial and lifestyle factors within Dutch integrated care for childhood overweight and obesity.

In order to address the aim, this study centers on two research questions:

What national and international scientific literature is available on psychosocial and lifestyle assessments for childhood obesity, and which factors do these assessments address?

What are experiences and views of HCPs with regard to assessing psychosocial and lifestyle factors within Dutch integrated care for childhood overweight and obesity?

The research process was iterative. To explore the first research question, a scoping review was performed by systematically searching databases for available national and international scientific literature on psychosocial and lifestyle assessments for childhood obesity and describing the factors that are addressed in these studies by doing a deductive analysis. For the second research question, online focus groups were organised with Dutch HCPs from a variety of disciplines and domains in order to explore their experiences and views with regard to assessing psychosocial and lifestyle factors within the Dutch integrated care by doing an inductive analysis.

Search strategy

A literature search was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement ( www.prisma-statement.org ) [ 20 ].

To identify all relevant publications, we conducted systematic searches in the bibliographic databases PubMed, Embase.com, APA PsycInfo (EBSCO), IBSS (ProQuest), Scopus and Web of Science from inception to 21 January 2022, in collaboration with a medical information specialist (RdV). The following terms were used (including synonyms and closely related words) as index terms or free-text words:

“Overweight”, “Obesity”, “Children”, “Patient history”, “Anamnesis”, “Psychosocial aspects”, “Lifestyle”.

Duplicate articles were excluded. All languages were accepted. The full search strategies for all databases are provided in the supplementary material.

Selection of articles

Studies were included if they met the following criteria: children with obesity aged 0–19 years and a description of an assessment of psychosocial and/or lifestyle factors, or systematic review of nutrition and/or physical activity assessments. We excluded studies if they: (i) were limited to only one dimension (e.g. nutrition, physical activity or medical assessment); (ii) concerned assessments related to patients who were screened for eligibility for bariatric surgery; (iii) were aimed exclusively at assessing motivation; (iv) were editorials, letters, legal cases or interviews. When full-text versions were not available, we contacted authors in an attempt to obtain complete information. Abstracts in languages other than English were translated.

Studies were screened in two stages using the Rayyan systematic review software. First, all relevant titles and abstracts were screened for eligibility (LK) using the inclusion and exclusion criteria, with the first 1000 titles and abstracts independently screened by one of the authors (EvdE). Differences in judgment were resolved through a consensus procedure. The two authors noticed complete agreement, therefore only one author (LK) screened all articles. If relevant, the full-text article was checked for the eligibility criteria. Second, the full-text articles were evaluated independently by two authors (LK and EvdE) for further review. A Microsoft Excel database for data management was created based on an iterative process. LK and EvdE discussed the eligibility, and differences were discussed until consensus was reached.

Data synthesis and analyses

For each article, the following data of the full-text articles were extracted in Microsoft Excel by spreadsheet: (i) year of publication; (ii) title; (iii) summary; (iv) target group; (v) study design; (vi) setting in which the assessment was conducted; (vii) how often and by whom the assessment was conducted; (viii) the format of the assessment; (ix) how the assessment was conducted by the HCPs; and (x) the content of the assessment.

The data synthesis was done by LK and EvdE and consisted of searching for consistency of patterns across the extracted data in Microsoft Excel and making comparisons between the extracted data of the studies with similar methodologies. Similarities were observed as a pattern and supplemented with any important distinguishing information. For example, nine articles focused on parent and family factors as part of the assessment which was seen as a similarity, whereas two articles only focused on child factors which was seen as a difference. Differences in how the data was analysed by screening the extracted data were discussed within the research team (LK, EvdE, CB, JS and JH) until consensus was reached.

Focus groups

Participants.

Professionals were recruited through the researchers’ professional national network and approached based on varieties in their professional background (healthcare practice, science and policy). The inclusion criterion for participation were knowledge of the supporting assessment tool and, preferably, the Dutch integrated care. Professionals were approached by telephone or by email and asked if they would be willing to participate in the study. Participants received a €10 webshop voucher.

Each participant received an information letter stating the reasons for conducting the research, and all provided recorded informed consent within the Zoom session to participate in this study. The study protocol was approved by the Medical Ethical Committee of the Amsterdam University Medical Center (METC number 2019.511).

Data collection

The focus group sessions were held between November 2020 and February 2021. Due to COVID-19 restrictions the sessions were conducted online using Zoom and lasted one and a half hour to 2 h. Each group consisted of four to nine participants. The sessions were conducted by two researchers with prior training in carrying out qualitative research. One of the researchers (LK) moderated the sessions, and another (EvdE) was an observer during the sessions. The focus group topic guide for each session was developed by LK and EvdE in consultation with the research team [see Additional file  1 ). The focus group topic guides were provided with input on the format of the assessments and the content of the assessment from national and international scientific literature (evidence based) and supplemented with themes from practice (practice based) based on gaps and needs as a result of an earlier performed study [ 19 ]. Professionals were asked to provide their availability and the interviews were scheduled based on when most professionals were available. Five focus group sessions were scheduled, with the order of the first four sessions based on the availability of the participants, the final focus group consisted of presenting the interim results and asking for additional input based on the first four focus groups. The focus groups (FG) were intended to generate insight into:

General experiences and views of CPs with the assessment (FG1)

Embedding of the assessment within the Dutch integrated care model (FG2)

Experiences with and views on other assessments (FG3)

Experiences with and views on the assessment of professionals other than CPs (FG4)

Embedding of the assessment within the practice of the Dutch integrated care by presenting the interim results and asking for additional input (FG5)

The sessions included interactive methods using the Mentimeter interactive presentation software to generate useful data and to receive input from each participant [available in Dutch on request]. The content of the discussion was audio-recorded and transcribed verbatim. Transcripts were summarised and sent to all participants, who were allowed time to complete or refine their statements as a member check.

Data analysis

Template analysis was used to thematically organise and analyse the data of the focus groups (inductive analysis) [ 21 , 22 , 23 ]. First, the researchers became familiar with the data by reading the transcripts, summaries, Mentimeter data, additions mentioned in the Zoom chat and field notes. Subsequently, for the initial template, LK performed the preliminary coding of the data, with a subset coded independently by EvdE (open coding). Emerging themes were organised into meaningful clusters (axial coding), and hierarchical relationships were defined (selective coding). LK and EvdE discussed discrepancies until consensus was reached with additional input from the research team (LK, EvdE, CB, JS and JH) and the initial version of the coding template based a subset of the data was defined. The coding template was applied to the remaining data. After necessary modifications and revisions, the template was finalised and applied to the full data set. The data were analysed using MAXQDA 2020 software. The Consolidated Criteria for Reporting Qualitative research (COREQ) were used to guide the reporting of the qualitative findings and has been included as supplementary information (see Additional file 5 ) [ 24 ].

Selection and description of included articles

The literature search generated a total of 8842 references: 1,755 in PubMed, 3478 in Embase.com , 532 in PsycInfo, 70 in IBSS, 1755 in Scopus and 1252 in Web of Science [see Additional file  2 ]. After removing duplicate references, 5376 references remained. The flow chart for the search and selection procedure is presented in Fig.  1 .

Flowchart for the search and selection procedure for articles

The 11 included articles are listed in Table  1 . Two articles focused only on child factors [ 27 , 30 ], whereas the others also focused on parent and family factors as part of the assessment [ 25 , 26 , 28 , 29 , 31 , 32 , 33 , 34 , 35 ]. Seven articles incorporated the broader healthcare process, including the assessment and the referral and treatment or weight management [ 26 , 27 , 28 , 29 , 32 , 33 , 34 ].

What to include in a psychosocial and lifestyle assessment

Factors that could potentially contribute to the development and maintenance of childhood obesity are presented in Table 2 . Assessment factors have been classified as child, family, parental and lifestyle factors and structured into psychological and social aspects. An extensive table with the original description of the factors has been included as supplementary information [see Additional file  3 ]. Although all articles described biomedical factors (e.g. anthropometric methods) as part of the assessment, these factors were not included in the present study [ 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 ]. In general, the articles devoted greater attention to biomedical factors than to psychosocial factors.

Psychosocial assessment

The extent to which psychosocial factors were described in the articles varied from elaborate descriptions, including assessment techniques and examples of questions for both children and parents [ 35 ], to a table containing brief descriptions of psychosocial problems [ 30 ].

Child factors

Psychological factors of the child included weight-related depression and anxiety, eating disorders, self-esteem and body image, which are specific to the assessment of childhood obesity, as opposed to more generic assessments [ 25 , 26 , 27 , 28 , 29 , 30 , 33 , 34 , 35 ]. Additionally, three articles included the identification of adverse events, such as major family events and a history of abuse or neglect [ 30 , 31 , 35 ].

In nine articles, social concerns (e.g. bullying, loneliness or problems with social interaction) were identified as social factors of the child [ 25 , 26 , 28 , 29 , 30 , 31 , 33 , 34 , 35 ]. Five articles noted to the importance of considering education (e.g. school avoidance and school performance) [ 28 , 30 , 33 , 34 , 35 ].

Family factors

One major aspect of social factors of the family identified in most assessments is the importance of determining family functioning in terms of environment, structure, composition or other aspects [ 25 , 26 , 28 , 31 , 32 , 33 , 34 , 35 ]. Four assessments included ethnicity and cultural factors, albeit to varying extents [ 25 , 26 , 28 , 29 ]. For example, one assessment in the form of a clinical guideline was specifically intended for minority populations (i.e. Maori, Pacific and South Asian populations) [ 29 ].

Parental factors

Four articles reported psychological factors of the parents that related to mental well-being. These articles differed in the extent to which the factors were described in relation to childhood obesity. Factors reported included adverse events, mental health concerns and eating disorders [ 26 , 31 , 34 , 35 ]. The social factor of the parents that was most prominently identified as being important to take into account was financial situation [ 25 , 26 , 31 , 32 , 33 ]. Six articles did not consider social parental factors [ 27 , 28 , 29 , 30 , 34 , 35 ].

Lifestyle assessment

Ten articles included the assessment of nutrition and physical activity as part of the lifestyle assessment [ 25 , 26 , 27 , 28 , 29 , 30 , 32 , 33 , 34 , 35 ]. The majority of the lifestyle assessments focused on the current lifestyle behaviour, and one article also focused on the adoption of desired healthy lifestyle behaviours by the entire family (nutrition education and physical activity) in addition to current lifestyle behaviour [ 30 ].

The specificity and extent of nutritional and physical activity assessment varied, as did the extent of resources provided to professionals. For example, one nutritional assessment offered a structured assessment to ensure the inclusion of relevant information concerning details of eating habits, including intake of sugar-sweetened beverages, milk and juices, fruits and vegetables, snacks and fast food, as well as appetite and portion size [ 28 ]. Physical activity assessments included details on time spent in a variety of activities or organised sports, transportation to and from school, time spent in sedentary behaviour and screen time per day.

The focus on the psychological and social aspects of nutrition and physical activity varied, and these aspects were not considered in a literature review and a clinical guideline for the examination and treatment of children and adolescents with obesity [ 27 , 28 ]. Psychological aspects of nutrition and physical activity were mentioned in six assessments and in relation to readiness to change and the level of confidence in the ability to make changes (self-efficacy) [ 25 , 29 , 30 , 31 , 33 , 35 ].

The majority of the assessments mentioned sleep behaviour as potentially contributing to excessive weight gain during childhood [ 25 , 26 , 27 , 28 , 29 , 30 , 32 , 35 ]. Most of the articles did not describe sleep patterns as part of lifestyle factors, but often as part of the biomedical assessment. For example, some assessments included the identification of various sleep-related problems, including disordered sleep, obstructive sleep apnoea syndrome and disruptive snoring [ 25 , 26 , 27 , 28 , 29 , 30 ].

How to conduct a psychosocial and lifestyle assessment

The included articles focused on what to include in a psychosocial and lifestyle assessment. Eight of these articles also paid attention to how to conduct the assessment of psychosocial and lifestyle factors [ 25 , 26 , 29 , 30 , 31 , 34 , 35 ]. These findings were divided into the three most prominent themes: (a) talking about psychosocial factors, lifestyle and weight; (b) the professional-patient relationship; and (c) attitudes of healthcare professionals.

Talking about psychosocial factors, lifestyle and weight

As noted by Barlow et al. and Varkula et al., it is important to communicate sensitively and introduce the topic carefully (e.g. by asking whether a patient or parent has any concern about the child’s weight) [ 25 , 35 ], as children and parents might feel ashamed and defensive about obesity [ 25 ]. They further advised HCPs to use the terms preferred by parents [ 25 , 35 ]. According to Jull, HCPs should avoid jargon and explain any health terms clearly, in addition to reflecting on their own communication preferences (e.g. the words and tone used; body language) [ 29 ].

Four articles paid explicit attention to behaviour change techniques (e.g. goal setting, stimulus control and self-monitoring) and conversational techniques (e.g. motivational interviewing) that should be applied [ 26 , 30 , 31 , 34 ]. According to Johansen et al., open-ended questions and reflective listening techniques could help direct communication towards changes in behaviour [ 26 ].

The professional-patient relationship

The importance of the professional-patient relationship was explicitly mentioned in articles by Jull et al. and Varkula et al. [ 29 , 35 ]. According to these two articles, early rapport building and a non-judgmental demeanour are of the utmost importance to the ideal assessment and management of childhood obesity. The authors stressed the vital importance of involving the family and engaging with children and families, building enhancing and collaborative relationships, and showing genuine respect [ 29 , 35 ].

Attitudes of healthcare professionals

As noted in studies by Barlow et al., Baur et al. and Jull et al., ideal assessment and management calls for HCPs to adopt an emphatic, supportive, non-judgmental and collaborative attitude [ 25 , 26 , 29 ].

Study characteristics

An overview of the self-reported general characteristics of the focus-group participants is presented as supplementary information [see Additional file  4 ]. In all, 28 professionals participated in the study, one of who participated in two focus groups. Four other professionals cancelled their participation due to personal circumstances. The mean age of the participants was approximately 45 years, and 25 (89%) of the participants were female.

The participants represented a total of 35 functions, as several participants combined multiple functions. The focus groups included professionals working 15 different positions at a variety of levels in the healthcare system, ranging from community care to secondary care: integrated (or general) care advisors ( n  = 8; 27.6%), YHC nurses ( n  = 6; 17.1%), CPs ( n  = 5; 14.3%), YHC doctor ( n  = 3; 8.6%), paediatricians ( n  = 2; 5,7%), project leaders of the local integrated care ( n  = 2; 5.7%), managers of the local integrated care ( n  = 2; 5.7%), specialised YHC nurses ( n  = 2; 5.7%), professor of nutrition and health ( n  = 1; 2.9%), social worker ( n  = 1; 2.9%), dietician ( n  = 1; 2.9%), researcher ( n  = 1; 2.9%) and trainer and developer of national education for CPs ( n  = 1; 2.9%). An overview of the distribution of positions is provided as supplementary information [see Additional file 4 ].

The participants represented a total of 29 different organisations, most within the municipal health services ( n  = 12; 41.4%). Other organisations included a municipality ( n  = 3; 10.3%), ‘Youth on a Healthier Weight’ (JOGG) ( n  = 3; 10.3%), a hospital ( n  = 2; 6.9%), the Netherlands Youth Institute ( n  = 2; 6.9%), the Dutch Centre for Youth Healthcare ( n  = 2; 6.9%), a dietician practice ( n  = 1; 3.5%), a university ( n  = 1; 3.5%), a primary school ( n  = 1; 3.5%) and a professional association ( n  = 1; 3.5%). One participant (3.5%) was self-employed. An overview of the organisations represented is provided as supplementary information [see Additional file 4 ].

Relevant factors that should be taken into account as part of the assessment have been classified as child, family, parental and lifestyle factors and structured into psychological and social aspects. According to the HCPs, there is no need to assess all these factors in detail at once, the CP makes the decision what is assessed and when it is assessed depending on the situation of the child and family.

Factors that participants identified as important to consider focused largely on the well-being of the child, stress and relaxation. The participants also emphasised the importance of discussing the strengths and capabilities of the child and family. Depending on the child’s age (predominantly with children aged 12 years and older), factors such as peer pressure, gaming behaviour and gaming in combination with sleeping were regarded as relevant.

When children go to secondary school, they often have money and go along with the group. Those who can’t afford to buy snacks between meals are in an awkward position, because the rest of the group is going, and they like these things as well. (Focus group 2, R5).

Participants emphasised the need to consider various aspects of family functioning, including the family situation and composition (e.g. separated parents and blended families) and mutual relationships between family members. They also mentioned the importance of assessing parenting skills, including the following topics: parental trust, setting clear boundaries, parental attitudes and beliefs with regard to upbringing, parental agreements on parenthood, and the experiences of parents with their own upbringing. According to the participants, co-caregivers (e.g. grandparents, daycare workers) who play a role in childcare and who bear some responsibility for upbringing should also be taken into account, given the critical importance of agreements on upbringing and lifestyle behaviour between caregivers.

Grandparents play an important role in families, and their views often conflict with those of the parents. Many parents are glad when grandparents are willing to take on a caregiving role. When grandparents want to reward children with fast food, sweets or salty snacks that the parents don’t approve of, however, this places the children under pressure. It’s obviously important for these things to be clear. The issue thus often goes beyond children and their direct caregivers to include the environment as well. (Focus group 4, R4, Pos. 53).

Finally, the participants noted that it is helpful to consider the environment of the family (e.g. social support, the networks of the parents, perception of weight by peers and culture).

And there should also be a cultural connection: the meaning of food in a family, sociability, hospitality, et cetera. (Focus group 2, R5, Pos. 96).

Participants noted the importance of considering whether parents have a job and what their work situation is. They also considered it important to talk about the financial possibilities, stress and relaxation of the parents.

I would like to see more attention to stress and relaxation, and what they need in that regard. This refers to factors that children experience as stressful, as well as those that parents see as stressful, as they are not necessarily the same. This is an important distinction. (Focus group 4, R4, Pos. 77).

Given that the focus groups centred on psychosocial factors, and given that participants felt that the current psychosocial and lifestyle assessment places sufficient emphasis on lifestyle factors, no additional lifestyle factors were mentioned.

It can be tempting to focus more on lifestyle issues and less on the underlying psychosocial issues or factors. I think people need more help in order to consider the issue more broadly. (Focus group 1, R4, Pos. 31)

The experiences and views of HCPs with regard to the assessment of psychosocial and lifestyle factors also addressed the issue of how to conduct the assessment of psychosocial and lifestyle factors. The findings emerging from the analysis of the focus-group discussions were classified according to the three most prominent themes: (a) talking about psychosocial factors, lifestyle and weight; (b) the professional-patient relationship; and (c) attitudes of healthcare professionals.

Participants emphasised the importance of talking about psychosocial factors, lifestyle and weight in order to gain insight into the factors that may contribute to the development and maintenance of obesity and to ensure a contextualised and comprehensive understanding of children with obesity and their circumstances. They specifically highlighted the sensitivity of the topic of obesity and some psychosocial factors. According to the participants, children and their parents may feel guilt and shame because of their weight, possibly leading them to avoid talking about obesity, psychosocial factors, lifestyle and weight, in addition to avoiding future appointments.

The way you introduce the conversation is important, given the vulnerability associated with obesity. The words used and questions asked are very important, as it can quickly seem like an interrogation. (Focus group 3, R6, Pos. 170).

The way you introduce the conversation is important, given the vulnerability associated with obesity. The words used and questions asked are very important, as it can quickly seem like an interrogation. (Focus group 2, R5, Pos. 159).

In order to prepare children and parents, participants stressed the crucial importance of explaining the need to assess the broader circumstances of children and their families, as they are likely to expect the assessment to focus only on weight and lifestyle. The participants also highlighted the need for CPs to acknowledge and explain the complexity of obesity. More specifically, children and parents should be aware of factors that influence their behaviour and weight. According to the participants, practical tools may help professionals to present interacting factors in a visual, non-judgmental manner, thereby facilitating conversations about psychosocial factors, lifestyle and weight.

Even if you already know the families, it’s important to explain why you want to take a broader look at the family at that particular moment. (Focus group 5, R8, Pos. 65).

We all know that conversations on this topic are difficult. It’s extremely important to explain why we’re asking these questions and what they actually have to do with each other. This is obvious to us, but not necessarily to parents. (Focus group 3, R6, Pos. 114).

Sufficient knowledge about the complexity of obesity, healthy food and the tools that are available were mentioned as important means of enabling professionals to conduct psychosocial and lifestyle assessments. Communication skills (e.g. applying various conversational techniques, such as motivational interviewing and solution-focused counselling) were also identified as a key element.

It requires interviewing skills to make contact in an interested, professional manner without going straight for the target. (Focus group 1, R2, Pos. 166).

Participants felt that it is more difficult to discuss psychosocial factors, lifestyle and weight with families with different cultural backgrounds who either have low literacy or face language barriers, and that the assessment thus needs more attention.

For parents with language problems, it is sometimes not until the second or third session that they start to understand what I meant when I asked if a dietician had already visited them or if they have had any previous help. I would actually have liked for that to have been the case at the first session. (Focus group 2, R5, Pos. 62) I’ve noticed that assessments are quite difficult when dealing with other cultures. It requires a lot of explanation, especially for people with a different background who don’t speak Dutch. This obviously makes the conversation quite different. (Focus group 2, R3, Pos. 22).

The participants regarded the professional-patient relationship as important to both the assessment and the management of childhood obesity. Given that it often takes considerable time to build rapport and a trusting relationship with children and their parents, the participants noted that multiple consultations may be required in order to conduct psychosocial and lifestyle assessments. I’ve also noticed that questions can be too daunting for a first conversation. There might still be some resistance if I were to try to address that right away. It sometimes takes several sessions before it’s safe enough. (Focus group 2, R4, Pos. 80).

With regard to the professional-parent relationship, CPs should 1) introduce their role and take time to explain the value of talking about psychosocial and lifestyle factors for both the child and the parents; 2) get to know the family better by asking about and trying to understand their living circumstances; and 3) create clear expectations about the care process.

I also think it’s good for coordinating professionals to introduce themselves: who I am and what I can do for them. This is not always clear to parents. (Focus group 5, R7, Pos. 70).

It’s really helpful to create a bond of trust and to help children and their parents to feel that you’re genuinely interested in them, and not just in the excess weight or how the child is eating and exercising. This completely changes the conversations. (Focus group 4, R4, Pos. 59).

Participants expressed that conducting a psychosocial and lifestyle assessment requires an attitude shift for most CPs. They stressed the need for CPs to be ‘demand-oriented’ and patient with regard to the priorities and requests of children and their families. Adopting an interested, curious and empathic attitude was considered helpful during the assessment. The participants highly endorsed the use of open-ended questions and engaging in active listening with a non-patronising attitude.

You have to have a particular mindset. You’re asking something completely different of professionals. Everyone might say, ‘Yeah, we know’. They might hear it, and it might sound good, but translating it into action really does ask something of them. (Focus group 1, R6 Pos. 39).

This article is based on scientific literature on childhood obesity assessments and information obtained from focus groups on the experiences and views of healthcare professionals (HCPs) with regard to assessing psychosocial and lifestyle factors that influence the development and maintenance of obesity. The results provide an overview of relevant psychosocial and lifestyle factors classified into four categories—child, family, parents and lifestyle—and structured into psychological and social aspects. The article also highlights the importance of paying attention to sensitivity when talking about psychosocial factors, lifestyle and weight within the context of such assessments, as well as the importance of a good professional-patient relationship and an emphatic, supportive, non-judgmental and collaborative attitude on the part of the HCP.

The scientific literature included in the scoping review reflected differences in the extent of detail in which various assessments address psychosocial and lifestyle factors, as well as with regard to other aspects that are addressed, including the management of obesity and how HCPs should conduct the assessment. Moreover, some of the literature provided an overview of principles of childhood obesity management, in addition to the psychosocial and lifestyle assessment [ 26 , 28 , 29 ]. One explanation for such differences could be that the articles included in the review were targeted at audiences in different healthcare disciplines and settings (e.g. medical professionals and mental healthcare professionals). Furthermore, the information obtained through the assessment might change throughout the healthcare process. In order to identify changes in the circumstances of children and their families, as well as to evaluate intervention outcomes and reconsider treatment goals, it would seem useful to integrate the assessment into the care process and assess psychosocial and lifestyle factors at several different points, rather than using such assessment exclusively as a diagnostic tool [ 36 ]. An appropriate assessment aimed at understanding factors that might contribute to the development and maintenance of obesity is essential to improving the efficacy of obesity management [ 37 ]. Such assessments can help to identify and address various facilitators and barriers. Studies have indicated that this can enhance the success of obesity treatments, in addition to increasing compliance with and adherence to treatment [ 38 ].

As indicated by the results of both the scoping review and focus groups, it is important to facilitate the work of HCPs by explaining how to conduct a psychosocial and lifestyle assessment. This finding is remarkable, given that the study was intended to search for available scientific literature on psychosocial and lifestyle assessments for childhood obesity, and experiences and views of healthcare professionals with regard to assessing psychosocial and lifestyle factors within Dutch integrated care, rather than to generate insight into how such an assessment should be conducted. One possible explanation could be that the notion of addressing psychosocial factors was unfamiliar to HCPs, as well as to children and their families, as standard obesity care to date has not devoted sufficient attention to such factors [ 39 , 40 ]. The participants in this study felt that conducting a psychosocial and lifestyle assessment is difficult. This might be due to the sensitive nature of the child’s weight and the risk that raising the issue of weight might alienate families or lead them to drop out of treatment [ 41 , 42 ]. In addition, the results of the scoping review and extensive research has documented the pervasive presence of implicit and explicit bias and stigma relating to weight, including amongst HCPs, and this has an impact on the care that they provide [ 43 , 44 , 45 , 46 , 47 , 48 ]. It could also lead children and their parents to avoid or delay healthcare services [ 45 , 49 ]. Given that bias and stigma relating to weight are driven by insufficient acknowledgement of the complex aetiology of obesity, efforts to build awareness and understanding concerning the complexity of obesity could help to reduce the prevalence of bias against obesity [ 47 ]. Visual materials that explain the complexity of obesity could be helpful in this regard, for instance an illustrated tool to support conversation [ 50 ]. The results of the scoping review and focus groups further highlight the importance of sensitive communication and a respectful and trustful patient-professional relationship when conducting psychosocial and lifestyle assessments, as these aspects could decrease the likelihood of stigmatisation, thereby making support and care more accessible to children and their parents [ 51 ].

The extent to which HCPs feel that they are able to conduct a psychosocial and lifestyle assessment seems to be related to years of work experience, affinity with the issues relating to overweight and obesity, level of knowledge, confidence in one’s own professional skills and the ability to adjust one’s attitude to correspond to individual children and their parents [ 19 ]. The role of these elements is well documented in the literature of the scoping review and other literature with regard to discussing a child’s weight, as well as when referring children to treatment and obesity counselling [ 19 , 46 , 52 ]. This is supported by the results of the scoping review and focus groups.

Limitation and strengths

A limitation of the scoping review is that it did not assess the methodological quality of the included studies as this did not add to the aims of the study. This stud intended to receive as many input and inspiration as possible with regard to psychosocial and lifestyle assessments which can be seen as a strength. In addition, a limitation of the focus groups is that the participants were not randomly selected as the inclusion criteria for participation were knowledge of the supporting assessment tool and, preferably, the Dutch integrated care. Since many of the participants had prior experience within the integrated care, they may not have been representative of all HCPs. Given the possibility of selection bias, the topics of this study might have been perceived differently by professionals with less experience with integrated care (e.g. because they need more support or guidance). However, the qualitative data reflect a variety of HCPs in terms of disciplines and professional experience. Moreover, the use of the Mentimeter interactive presentation software during the focus groups ensured the collection of a wide variety of input, as it allowed for obtaining additional information from each individual participant. Finally, data saturation was achieved, as indicated by the confirmation of the themes and conclusions in the final focus group.

One strength of this study is that two methods were used involving the use of qualitative data from focus groups to expand on and add depth to the results of a systematic literature review. In addition, the use of databases for the fields of healthcare, social work and psychology ensured that the scoping literature review reflects a wide range of literature, thereby enhancing the generalisability of the findings.

Implications for practice and future research

Although the role of the coordinating professional (CP) is specific to the context of the healthcare system in the Netherlands, the findings may also be relevant to childhood obesity care in other Western countries. Given that the results reflect lessons learned with regard to what should be included in psychosocial and lifestyle assessments and how such assessments should be conducted, they might also be applicable to for adults and for other chronic diseases.

The results of the scientific literature and experiences and views of HCPs are synthesized and used to develop practical tools for HCPs within the context of integrated care in the Netherlands [ 50 , 53 , 54 ]. Developing practical tools for HCPs based on the results of the scoping review and focus groups of this study that corresponds to the national and local contexts within which they provide obesity care might also be relevant for other integrated care contexts, including: (1) examples of questions concerning psychosocial and lifestyle factors; (2) inspiration for obtaining deeper insight into psychosocial and lifestyle factors (e.g. health related quality of life) [ 55 ]; (3) suggestions concerning how to talk about psychosocial and lifestyle factors in a positive and structured manner; and (4) guidance for what HCPs should do after the assessment. The involvement of HCPs as well as children and parents in the development of appropriate tools could increase the likelihood of successful implementation. Another practical implication is that age-appropriate visual materials that provide insight into the complexity of obesity should be developed in order to support the process of conducting psychosocial and lifestyle assessments. Finally, it is important for HCPs to be trained to conduct psychosocial and lifestyle assessments, as this could enhance their confidence and skills, while contributing to de-stigmatisation. HCPs will need time to experiment with the tool, and they will need to gain experience with how to personalize to the needs and priorities of individual children and their parents. The practical implications of this study are already being applied within the context of integrated care in the Netherlands [ 50 , 53 , 54 , 56 , 57 ].

Future research should focus on evaluating psychosocial and lifestyle assessments with HCPs, as well as with children and their parents, in order to identify their needs and wishes, as current research does not adequately reflect their voices. Studies should also address the impact of conducting a psychosocial and lifestyle assessment as part of the integrated care process on the outcomes of care.

This study provides an overview of psychosocial and lifestyle factors that should be identified and how they should be addressed in order to personalise childhood obesity care as part of integrated care for childhood overweight and obesity. These insights can be translated into practical tools for facilitating HCPs in the process of conducting psychosocial and lifestyle assessments in a sensitive and adequate manner. Future research should evaluate the needs, wishes and experiences not only from the perspective of HCPs, but also from the perspective of children and their families. This will promote continuous learning and thereby the further development of the integrated care and the tools associated with it. In addition, the impact of such developments on the outcomes of care should be monitored.

Availability of data and materials

All data generated or analysed during this study are included in this published article and the supplementary information files. The data analysed during the current study are available upon reasonable request from the corresponding author ( [email protected] ).

Abbreviations

Coordinating professional

Youth healthcare

Healthcare professional

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Acknowledgements

We are grateful to the healthcare professionals who took part in the study. We would like to thank Minke Eilander for her support during the research, Lamyae Boutalab for her support during the additional search and in writing the manuscript and Bibian van der Voorn for her support in writing the manuscript.

This project was carried out as part of the Care for Obesity project, which was funded by the Dutch Ministry of Health, Welfare and Sport (grant number 328544, 329657, 977473, 332401). The funder did not have any role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. This study was carried out by Care for Obesity (Vrije Universiteit Amsterdam).

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Contributions

LK, EvdE and JH contributed to the conception and design of the study with additional input from CB and JS. RdV identified all relevant publications for the literature search in collaboration with LK and EvdE. LK and EvdE performed the literature search, in collaboration with RdV. LK and EvdE conducted the focus groups. LK and EvdE performed data analysis, with additional input from CB, JS and JH. LK led the writing of the manuscript. All authors (LK, EvdE, EvM, MvdV, RdV, CB, JS and JH) edited, read and approved the final manuscript.

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LK: she is a PhD student at the Department of Health Sciences, Vrije Universiteit Amsterdam.

EvdE: she is a PhD student at Erasmus MC, University Medical Center Rotterdam.

EvM: he is a pediatric endocrinologist at the Jeroen Bosch Hospital in ‘s-Hertogenbosch and a professor of Nutrition and Health at the Maastricht University.

MvdV: she (MSc) is a manager of the childhood overweight and obesity approach at the Municipal Health Services of the municipality Amsterdam.

RdV: he (Msc) is an information specialist at the Medical Library, Vrije Universiteit Amsterdam.

CB: she is a professor of Integrated Health care at Tranzo, Tilburg University.

JS: he is a professor of Nutrition and Health at the Department of Health Sciences, Vrije Universiteit Amsterdam.

JH: she is an assistant professor childhood obesity at the Department of Health Sciences, Vrije Universiteit Amsterdam.

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All methods were carried out in accordance with relevant guidelines and regulations. Each participant received an information letter stating the reasons for conducting the research, and all gave recorded informed consent within the Zoom session to participate in this study. The study protocol was approved by the Medical Ethical Committee of the Amsterdam University Medical Center (METC number 2019.511).

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Supplementary Information

Additional file 1. .

Focus group sessions topic guides.

Additional file 2. 

Literature search results.

Additional file 3. 

Extensive table containing the original descriptions of factors that may contribute to the development and maintenance of childhood obesity and that should therefore be identified.

Additional file 4. 

Additional file 5. .

Consolidated criteria for reporting qualitative studies (COREQ): 32-item checklist.

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Koetsier, L.W., van den Eynde, E., van Mil, E.G.A.H. et al. Scoping literature review and focus groups with healthcare professionals on psychosocial and lifestyle assessments for childhood obesity care. BMC Health Serv Res 23 , 125 (2023). https://doi.org/10.1186/s12913-022-08957-5

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Literature review: Considerations in undertaking focus group research with culturally and linguistically diverse groups

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Aims. This integrated literature review seeks to identify the key considerations in conducting focus groups and discusses the specific considerations for focus group research with culturally and linguistically diverse groups. Background. The focus group method is a technique of group interview that generates data through the opinions expressed by participants. Focus groups have become an increasingly popular method of data collection in health care research. Although focus groups have been used extensively with Western populations, they are a particularly useful tool for engaging culturally and linguistically diverse populations. The success of focus groups in this context is dependent upon the cultural competence of the research team and the research questions. Methods. The electronic databases Medline, CINAHL, Embase, Psychlit and the Internet using the Google Scholar search engine were explored using the search terms 'focus group', 'cultural sensitivity', 'transcultural nursing', 'transcultural care', 'cultural diversity' and 'ethnic groups'. Hand searching of reference lists and relevant journals was also undertaken. English language articles were selected for the review if they discussed the following issues: (i) methodological implications of the focus group method; (ii) strengths and limitations of the focus group method; (iii) recommendations for researchers and (iv) use of the focus group in culturally and linguistically diverse groups. Conclusions were drawn from each of the articles and consensus regarding a summary of recommendations was derived from a minimum of two authors. Results. Findings from this review revealed several key issues involving focus group implementation including recruitment, sample size, data collection, data analysis and use within multicultural populations. Strengths and limitations of the focus group method were also identified. Conclusions. Focus groups are a useful tool to expand existing knowledge about service provision and identify consumer needs that will assist in the development of future intervention programmes, particularly within multicultural populations. Careful planning related to methodological and pragmatic issues are critical in deriving effective data and protecting participants. Relevance to clinical practice. Focus groups can facilitate increased understanding of perspectives of culturally and linguistically diverse groups and thereby shape clinical practice to better meet the needs of these groups.

• Focus groups
• Multicultural populations
• Qualitative research
• Research methods

ASJC Scopus subject areas

• General Nursing

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• Focus Groups Medicine & Life Sciences 100%
• Transcultural Nursing Medicine & Life Sciences 13%
• Population Medicine & Life Sciences 11%
• Cultural Diversity Medicine & Life Sciences 10%
• Cultural Competency Medicine & Life Sciences 10%
• Search Engine Medicine & Life Sciences 9%
• Health Services Research Medicine & Life Sciences 8%
• Nursing Care Medicine & Life Sciences 7%

T1 - Literature review

T2 - Considerations in undertaking focus group research with culturally and linguistically diverse groups

AU - Halcomb, Elizabeth J.

AU - Gholizadeh, Leila

AU - DiGiacomo, Michelle

AU - Phillips, Jane

AU - Davidson, Patricia M.

PY - 2007/6

Y1 - 2007/6

N2 - Aims. This integrated literature review seeks to identify the key considerations in conducting focus groups and discusses the specific considerations for focus group research with culturally and linguistically diverse groups. Background. The focus group method is a technique of group interview that generates data through the opinions expressed by participants. Focus groups have become an increasingly popular method of data collection in health care research. Although focus groups have been used extensively with Western populations, they are a particularly useful tool for engaging culturally and linguistically diverse populations. The success of focus groups in this context is dependent upon the cultural competence of the research team and the research questions. Methods. The electronic databases Medline, CINAHL, Embase, Psychlit and the Internet using the Google Scholar search engine were explored using the search terms 'focus group', 'cultural sensitivity', 'transcultural nursing', 'transcultural care', 'cultural diversity' and 'ethnic groups'. Hand searching of reference lists and relevant journals was also undertaken. English language articles were selected for the review if they discussed the following issues: (i) methodological implications of the focus group method; (ii) strengths and limitations of the focus group method; (iii) recommendations for researchers and (iv) use of the focus group in culturally and linguistically diverse groups. Conclusions were drawn from each of the articles and consensus regarding a summary of recommendations was derived from a minimum of two authors. Results. Findings from this review revealed several key issues involving focus group implementation including recruitment, sample size, data collection, data analysis and use within multicultural populations. Strengths and limitations of the focus group method were also identified. Conclusions. Focus groups are a useful tool to expand existing knowledge about service provision and identify consumer needs that will assist in the development of future intervention programmes, particularly within multicultural populations. Careful planning related to methodological and pragmatic issues are critical in deriving effective data and protecting participants. Relevance to clinical practice. Focus groups can facilitate increased understanding of perspectives of culturally and linguistically diverse groups and thereby shape clinical practice to better meet the needs of these groups.

AB - Aims. This integrated literature review seeks to identify the key considerations in conducting focus groups and discusses the specific considerations for focus group research with culturally and linguistically diverse groups. Background. The focus group method is a technique of group interview that generates data through the opinions expressed by participants. Focus groups have become an increasingly popular method of data collection in health care research. Although focus groups have been used extensively with Western populations, they are a particularly useful tool for engaging culturally and linguistically diverse populations. The success of focus groups in this context is dependent upon the cultural competence of the research team and the research questions. Methods. The electronic databases Medline, CINAHL, Embase, Psychlit and the Internet using the Google Scholar search engine were explored using the search terms 'focus group', 'cultural sensitivity', 'transcultural nursing', 'transcultural care', 'cultural diversity' and 'ethnic groups'. Hand searching of reference lists and relevant journals was also undertaken. English language articles were selected for the review if they discussed the following issues: (i) methodological implications of the focus group method; (ii) strengths and limitations of the focus group method; (iii) recommendations for researchers and (iv) use of the focus group in culturally and linguistically diverse groups. Conclusions were drawn from each of the articles and consensus regarding a summary of recommendations was derived from a minimum of two authors. Results. Findings from this review revealed several key issues involving focus group implementation including recruitment, sample size, data collection, data analysis and use within multicultural populations. Strengths and limitations of the focus group method were also identified. Conclusions. Focus groups are a useful tool to expand existing knowledge about service provision and identify consumer needs that will assist in the development of future intervention programmes, particularly within multicultural populations. Careful planning related to methodological and pragmatic issues are critical in deriving effective data and protecting participants. Relevance to clinical practice. Focus groups can facilitate increased understanding of perspectives of culturally and linguistically diverse groups and thereby shape clinical practice to better meet the needs of these groups.

KW - Focus groups

KW - Multicultural populations

KW - Nurses

KW - Nursing

KW - Qualitative research

KW - Research methods

UR - http://www.scopus.com/inward/record.url?scp=34249021069&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=34249021069&partnerID=8YFLogxK

U2 - 10.1111/j.1365-2702.2006.01760.x

DO - 10.1111/j.1365-2702.2006.01760.x

M3 - Review article

C2 - 17518876

AN - SCOPUS:34249021069

SN - 0962-1067

JO - Journal of clinical nursing

JF - Journal of clinical nursing

The key success factors in focus group discussions with the elderly for novice researchers: a review

Journal of Health Research

ISSN : 2586-940X

Article publication date: 6 March 2020

Issue publication date: 7 August 2020

This study aimed to discuss the key success factors in focus group discussions among the elderly as a means of supporting novice researchers and also to share the experiences of novice researchers with focus group discussions.

Design/methodology/approach

This study used a literature review of previous studies that revealed three themes regarding the key success of focus group discussions with the elderly. Focusing on issues published between 2009 and 2019, four health-related databases, namely the Cumulative Index of Nursing and Allied Health Literature (CINAHL), ScienceDirect, PsycARTICLES and Thaijo were investigated using keyword searches, both individually and in combination, and the inclusion criteria used in selecting relevant articles as primary sources included research written in the English and Thai languages.

The literature review involved eight published articles related to this topic in the nursing field. Three themes for key successes were identified as follows: good planning and convenient organization, being accepting and flexible concerning their opinions and good management.

Originality/value

Focus group discussions with the elderly are complex and challenging for novice researchers. It is necessary that a novice researcher in the nursing field builds up the skills of a moderator in conducting focus group interviews if he or she wishes to obtain rigorous data.

• Focus group discussion
• Novice researcher

Muijeen, K. , Kongvattananon, P. and Somprasert, C. (2020), "The key success factors in focus group discussions with the elderly for novice researchers: a review", Journal of Health Research , Vol. 34 No. 4, pp. 359-371. https://doi.org/10.1108/JHR-05-2019-0114

Emerald Publishing Limited

Copyright © 2019, Kasorn Muijeen, Puangpaka Kongvattananon and Chomchuen Somprasert

Published in Journal of Health Research. Published by Emerald Publishing Limited. This article is published under the Creative Commons Attribution (CC BY 4.0) license. Anyone may reproduce, distribute, translate and create derivative works of this article (for both commercial and non-commercial purposes), subject to full attribution to the original publication and authors. The full terms of this license may be seen at http://creativecommons.org/licences/by/4.0/legalcode

Introduction

Qualitative research on the elderly population requires understanding on the part of the researcher perhaps more than that required for other age groups because these members of the population have had a great deal of life experience, and some are very knowledgeable. Some, however, have not been very successful in life. This range makes focus group discussions a challenge. Collecting the qualitative research data for the present study focused on methods that were consistent with the natural way of life of people in society. In Thai society, especially in Thai villages, people often talk in groups at leisure or while carrying out activities where they can carry on a conversation at the same time. Therefore, group discussion is a normal social behavior in communities or societies that are familiar with each other. Qualitative researchers sometimes use this activity as a data collection method [ 1 ]. Focus group discussion in qualitative research refers to a data collection method that focuses on discussing and exchanging opinions and experiences with the participants. Moreover, with this method, the researcher can observe the participants' interactions with each other and talk to them, thus covering the various issues that have emerged during the conversation and using them for further analysis [ 2 ].

Research on the elderly in Thailand has generally focused on illness and disability. However, for the past decade, this trend has been expanded and now, “successful or healthy aging” or “healthy elderly” are issues that are discussed [ 3 ]. The increasing number of elderly people in the world has resulted in the need to study more deeply the factors that influence the health of older people [ 4 ] and perhaps especially understand why some older people seem to adapt to the challenges of the aging process whilst others cannot despite interventions and policies targeted at them. Therefore, qualitative research on the elderly is often focused on certain aspects, such as health awareness or the health literacy of the elderly [ 5 ]. Focus group discussions with the elderly, on the other hand, are a popular method of collecting data for qualitative research purposes. However, focus groups represent a challenge for new researchers in terms of collecting qualitative data. Novice researchers are typically concerned about the process of focus groups with the elderly and need to understand the characteristics of this special group. The main responsibility of the moderator in this context is to create discussions that offer useful responses got from the participants [ 6 ]. Moreover, the novice researcher needs to be aware of these factors because the focus group discussion provides a quick approach to research which may require considerable time for analysis. Careful planning regarding the moderation of focus group discussions is the basis for successful qualitative research [ 7 ] in this area. When using the discussion group method, preparation has many aspects, and effort must be made so that the time and effort will not be wasted [ 8 ].

The processes of focus group discussions with the elderly are challenging for new researchers who need previous experience on conducting such discussions or previous experience with being a moderator, all of which are a part of the data collection method in qualitative research. Addressing issues such as good planning and organizing the participants and facilities, as well as training, to understand the characteristics of being a good moderator, as well as having an accepting attitude and being flexible are key to the success of group discussions for novice researchers. In addition, several studies have shown that success in conducting focus groups mainly derives from the characteristics of an effective facilitator or moderator. In addition, training and personal readiness are essential in order to enhance the moderator's skills [ 9 , 10 ].

This study has two main points of interest. The first is to understand the factors required in order to conduct focus group discussions amongst the elderly for novice researchers. The second is to describe the researcher's experience with others by sharing the experience of the following published project: “The Effects of Using a Knowledge-management Development Program on Knowledge Management Behaviors for the Health Promotion of Elderly Leaders in the Romyen Community in Thailand” [ 11 ]. The study's objective provides a discussion of the key success factors of focus group discussions with the elderly for novice researchers.

Selection criteria and search strategy

A systemic review was used on articles published between 2009 and 2019, using four health-related databases, namely the Cumulative Index of Nursing and Allied Health Literature (CINAHL), ScienceDirect, PsycARTICLES and Thaijo, which were investigated using keyword searches.

Systemic and critical reviews used the guiding framework based on the PRISMA 2009 flow diagram [ 12 ], which is composed of four steps as follows: identification, screening, eligibility, and included. From the database, 377 studies published from January 2009 to March 2019 were identified that could be adapted as a PRISMA 2009 flow diagram for the article selection process, as shown in Figure 1 . The process of searching began with step 1 as follows: identification using the keywords used within the database search, both individually and in combination, including the terms “key success,” “moderator,” “facilitator,” “conduct,” “focus group discussion with the elderly,” “focus group discussion with older adults,” “novice researchers” and “experience novice researchers.” Step 2 included the screening of articles from the inclusion criteria used in selecting relevant articles as primary sources. This was research written in the English and Thai languages, while the exclusion criteria were articles written in other languages and that were not related to the novice or new researcher as a moderator in focus group discussions with the elderly or focus group discussions with older individuals. Step 3 concerned eligibility, where the full text of the article was examined by checking the content or details of the investigation, as depicted in Figure 1 , for a total of 25 full articles repossessed and checked for eligibility. Step 4 included twenty-five eligible articles to be considered; however, sixteen articles did not have a moderator in the focus group. Finally, the nine remaining articles were qualitative and quantitative studies synthesized by the author, as shown in Figure 1 .

Study selection and data extraction

The data extracted from the studies were tabulated independently by the authors, with data including the study design, purpose and key content or findings of the studies. The findings or the key content were related to the factors connected with focus group discussions, such as the skill of the moderator and how to conduct a focus group discussion.

Ethical consideration

This study did not involve human participants but rather used a literature review of previous studies.

The main results were derived from information gathered from nine articles related to the key success factors regarding focus group discussions among the elderly with novice researchers. These nine articles were divided into two parts as follows: the first part concerned the research and literature related to focus group discussions, as can be seen in the seven articles presented in Table I ; and the second part concerned research that used focus group discussion strategies with the elderly, as shown in Table II .

The main messages from each paper were presented after a thorough analysis, as seen in Tables I and II . According to the information in Table I , the study [ 13 , 15 ] presented the steps of a focus group, including planning and good communication skills for conducting focus group discussions consistent with Doody [ 9 ], who mentioned the environment and duration of the focus group as being important factors. An effective moderator should be a good listener and possess good communication skills. Moreover, Wilson [ 16 ] described planning and the role of the moderator as being important as well. As indicated, the size of the focus group depends on the complexity of the topic and the skill of the moderator [ 14 ]. A skillful moderator needs to know the topic in depth or should be an expert in the subject of discussion [ 17 ]. Technology can also affect the focus group [ 18 ]. Table II [ 19 , 20 ] supports the characteristics of the elderly participant group and how to create a successful focus group discussion. According to the data, the relevant information concerning how to successfully complete a focus group discussion with the elderly can be summarized according to three key success factors as follows: 1) Good planning and event organization, 2) Be accepting and flexible concerning their opinions and 3) Have good management skills.

Good planning and event organization

The stage of good planning and event organization includes preparation, the presession and the session itself. These are important points for novice researchers in terms of conducting a successful focus group discussion. Good planning and event organization should cover the researcher's team, the participants, the environment and question creation in line with the objectives of the focus group. The participants should be contacted in advance and be made aware of the objectives of the activity. It is important to select suitable persons for the focus group. The researcher has to give careful attention to time and provide enough time to prepare. This covers the duration of the focus group, the selection of the participants, the size of the group, preparing the environment, conducting the focus group, supporting the participants during the interview and the participants’ role as a moderator. Wilson [ 16 ] recommends that the moderator reviews the literature on the topic, prepares to take field notes and prepares his or her role in advance. Questions should also be prepared in advance with the research team, considering the purpose of the study, and especially for the elderly, the questions should be relatively easy. In addition, in order to collect comparable data from all of the focus group discussion participants, a list of broad questions or predetermined probes can be developed as a guide for the moderators in order to facilitate the discussion among the participants. Some of the questions in a focus group discussion from Reichstadt's study [ 21 ] are, for example, “How would you define successful aging?” and “What are the necessary components of successful aging?” These questions can guide the moderator in conducting the group and will help him or her explore the research problem. In each focus group, the moderators can begin with these broad questions, with further questions asked based on the participants' responses, in order to elicit additional opinions from the group. This ensures that the participants are provided with an opportunity to discuss their personal attitudes and beliefs [ 1 ]. For the conclusion stage, the moderator should choose approximately five factors related to how to be successful in the focus group discussion, including the size of the focus group, the timing, the environment and location, the selection of participants and understanding the participants and focus group scripts and materials.

Size of the focus group

Variations exist in the literature regarding the optimum size of a focus group, depending on the complexity of the topic, the type of participants and the skills of the moderator. Most researchers suggest that the appropriate group size ranges from 4 to 12 participants [ 1 , 2 , 6 ]. A large group can generate more opinions and/or feelings about the topic, while a smaller group may be more beneficial when sensitive issues are concerned. Moreover, the number of participants in the focus group can depend on the participants having the same experience because some experiences take a long time to discuss and, for this reason, the group should be a small group [ 22 ]. Therefore, the size of a focus group can vary according to the research objective, can be flexible and should be large enough to create a group discussion. For example, most focus group discussions with the elderly in Thailand have 6–12 participants [ 19 – 21 ].

Time of the focus group

The period of time for conducting the focus group depends on the complexity of the topic, the number of questions asked and the size of the group. The duration of the focus group discussion should be in the range of 1 to 2 hrs and should not be longer than 2 hrs because this can affect the physical and mental health of the participants, especially among the elderly, who often have problems with their physical health and are tired from the effects of old age [ 21 ]. Barbour [ 2 ] recommends that the time for discussion be limited to 45 to 90 mins because outside this time period, the participants may lose their ideas and thoughts about the topic, or the session time would have been reached. However, a period of less than 1 hr may prevent the discussion of important issues in accordance with the research objectives. Therefore, it is recommended to use a flexible time period of one hr to no more than 2 hrs.

The environment and location

The environment and location are important as they can have a significant impact on the discussion of a focus group. The following have been suggested concerning the environment and location of a focus group discussion among the elderly: (1) the room should be of adequate size, lighting and temperature; (2) the seating should be arranged in a circle format to ensure that all the participants can see one another, and the ergonomic characteristics of the elderly should be considered; for example, chairs should not be too high or too low because most older people have problems with their knees; (3) the moderator should create a relaxing atmosphere, comfortable and nonthreatening, and the participants should not feel that the questions are too abstract, for example using academic language and (4) the location or setting should be a safe environment where disturbances from other people or external noise [ 14 , 15 ] are not present.

Selection of participants and understanding the participants

The groups can be homogeneous or heterogeneous, depending upon the purpose of the research; yet, attendees should have previous experience or prior knowledge of the topic. Homogeneous groups have similar characteristics, such as being from the same background, being close to the same age, of the same gender, social status or occupation and having experience with the topic as these factors may influence the group discussion. However, heterogeneous groups could be used for exploratory purposes where varieties of groups are preferred. Moreover, it is important to make sure that the focus group participants are not in conflict with one another or are incompatible. Pawi [ 17 ], for example, discussed the differences in the research outcomes obtained from homogeneous and heterogeneous groups, as well as the differences between groups of individuals that were familiar with each other or intimate and those that were strangers. Therefore, novice researchers need to understand all of the steps of the focus group discussion. The novice researcher should carefully select the participants in the group because this will help him or her achieve the research objectives and make it easier to control the focus group discussion. In the Thai context, the novice researcher can use respectful pronouns instead of calling people by their proper names, such as uncle and aunt, when they conduct a group. In addition, the novice researcher must try to find out which of the elderly participants have hearing problems, and while he or she is moderating a focus group discussion his or her speaking volume must not be too loud or too low, and questions may have to be repeated [ 19 , 20 ].

Focus group scripts and materials

Nagle and Williams [ 22 ] stated that the lack of important equipment or materials could interrupt or even stop the discussion from flowing smoothly, causing participants to feel uncomfortable and limiting the discussion. The moderator could prepare a script as an outline for the focus group discussion. The scripts for introducing the group discussion can include, for example, the following: (1) welcoming statements, including the process of self-introduction and group member introductions, with members providing general stories about themselves; (2) overviewing the topic; they can begin by explaining the purpose of the study and of the focus group; (3) stating the ground rules, reviewing the group discussion rules and other information that the participants need to know prior to the group interview and (4) beginning with the first question. It is also important that the questions in the scripts move from the general to the more specific or in order of importance. The research team should brainstorm in order to develop a list of questions based on the purposes of the research. These should be open-ended rather than yes–no questions, to generate more useful information from the group discussion.

O'Connor and Murphy [ 15 ] suggested that creating focus groups for the elderly has nine components that help to complete the group, which can be summarized as follows: (1) audiotapes or audio cassettes used to record the data; (2) participant information form and consent form; (3) labels for the participants and moderators; (4) a watch (5) coffee and bakery goods or drinks; (6) a sign-in consent form and a document listing the participants; (7) flip charts and markers and (8) notebooks, pens and audio cassettes that can be used for recording the data. Digital voice recorders are important because recording focus group discussions is not easy. Focus groups are notoriously difficult to manage and control, especially amongst the elderly, who may speak softly, which makes for poor recording [ 18 ].

Being accepting and flexible concerning their opinions

By recognizing the importance of the moderator role, the novice researcher should gain insight into the requirements of this role in order to promote his or her effectiveness. One's life and work experience may provide a level of preparation, but the development of additional skills can be carried out with the following: theoretical knowledge practice using open-ended questions and rewriting; being familiar with many group conversations; conducting a pilot study; talking to researchers that have had experience in using group discussion methods and participation in focus group discussions for the purpose of critical analysis. A novice researcher should understand that teamwork is important, and various techniques can be used to help solve the problems that may arise during the decision-making process because it is difficult for only one person to manage and conduct a complete focus group. Conducting a focus group is difficult for a novice researcher, especially regarding the data collection and the work process of the focus group. Accepting comments and being flexible are the challenges for moderators to improve their skills, including the following; good interpersonal skills, being good listeners and being non-judgmental and adaptable.

Good interpersonal skills

The interpersonal skills of the moderator are crucial to success in conducting a focus group. Shaha et al. [ 13 ] agree that interpersonal and group leadership skills are essential. At the beginning of the group interview, a moderator welcomes all participants and introduces himself or herself and the team. He or she then requests the participants to introduce themselves and to put on a name label. Then, he or she identifies the purpose of the interview, asks an introductory question as a warm-up to create a relaxing atmosphere and thanks them afterward for sharing their experience. Moreover, Krueger and Casey suggest that light refreshments and eating together tend to promote conversation, discussion and communication within the focus group. Nagle and Williams [ 22 ] suggest that the communication skills of the moderator also involve how to deal with interruptions when someone is providing an opinion. In this regard, the moderator should provide some signals for them to wait, explaining that they will be given an opportunity to speak next. In Thailand, most focus group discussions with the elderly are significant because of research carried out by the moderator and his or her relationship with the group [ 20 ]. If the relationship between the group participants and the moderator is good, insightful information can be received and the research questions can be answered. On the other hand, if the relationship is not good at the outset, the group operation will have obstacles.

Being good listeners

A moderator must be a good listener and a thinker at the same time. Curtis and Redmond [ 23 ] stated that a moderator is required to concentrate on the discussion and to observe the level of the participants' interaction during a group discussion. Packer–Muti [ 10 ] suggested that a moderator should listen attentively with sensitivity and empathy, and Mack et al. [ 24 ] pointed out the importance of reading the body language of the participants, including crying, which can be related to the content of the discussion, in which case the moderator must not join in the emotion or outwardly express sympathy. In addition, the moderators must listen intently while engaging with the other participants, without expressing emotions themselves. If a problem occurs in a dynamic group, the group of responders will respond accordingly, with the moderator warning the participants about the rules of participation in the focus group. However, the important thing to consider is that the participants are elderly and when they speak the moderator must actively listen.

Be non-judgmental and adaptable

The moderator must accept that the participants may be inclined to divert from the expected answers or thought patterns, in response to questions. Mack et al. [ 24 ] mentioned that a moderator should believe that all participants have ideas on the topic and that the moderator should be impartial with his or her general opinions. Nagle and Williams [ 22 ] recommend that a moderator avoid head nods or responses such as “yes,” “I agree” and “OK.” These responses convey acceptance of the answers, which can limit the findings and/or any new ideas or opinions that may come later from other participants in a group. A good moderator needs to have an adaptable and non-judgmental attitude with no partiality or bias toward any of the group participants.

Good management of group dynamics

During a focus group, the researcher recognizes the potential tension between participants with certain characteristics or attitudes. Unfortunately, occasionally, group dynamics cannot be identified at the beginning of a session. The moderator plays the important role of the manager in creating the appropriate group process in which all the participants can participate in the discussion and exchange ideas. However, some group dynamics cannot be predicted. There have been many suggestions for moderators concerning how to deal with disruptive group dynamics, such as countering dominating or disruptive group members and concerning shy or silent participants. However, the researcher's experience will help to resolve problems with disruptive members or barriers in the group dynamics. This study provides details of the experience of novice researchers in the implementation of focus group discussions for the elderly, as detailed below.

The experience of novice researchers in focus groups for the elderly

This section of the present paper explains theresearcher's experience with other researchers by sharing her direct experience from the project mentioned above. The feeling of the author during the first focus group amongst the elderly was one of excitement. The author strongly agrees that good planning and convenient event organization, being accepting and flexible and practicing good management of the group's dynamics are important factors to make the focus group a success for new researchers. However, in conducting that focus group, where the elderly expressed all of their opinions, the data were still incomplete in relation to the objectives, which will be discussed in greater detail in the next section.

As Thai society is developing into an aging population, the elderly population is an important group. Therefore, there has been a great deal of education about elderly groups, and it can be said that qualitative research has allowed researchers to find answers concerning the elderly in profound ways. Based on the literature review and the shared experiences of the author in conducting focus groups with the elderly, it can be concluded that the keys to success include all of the three steps discussed above because they represent the sequence of events that will occur in focus group discussions.

Good planning and convenient event organization represent the preparation process, and these are important for a successful group discussion. The experience of the author in the research project mentioned above can be described as follows: the size of the group from this research comprised five elderly participants in a homogenous group of females who had the same experience with knowledge management training projects. It was concluded that the research team should meet and prepare itself before beginning the focus group, including reading about and understanding the research objectives and sharing the duties for preparation in various steps [ 14 , 20 ].

The skill of being a good listener and being non-judgmental needs to be practiced, and more experience in conducting focus groups is required [ 20 , 21 ]. The experience of this author could provide an example of the skills of the moderator and suggests that creating a focus group with the elderly also requires building relationships rather than just using friendly questions. Moreover, being a good listener and being non-judgmental and adaptable are important examples from the author's experience, and the moderator would be advised to be a quick decision-maker, especially when the participants talk too much. The moderator should make conclusions and lead to the next topic, and he/she should invite other participants to share their opinions. An example can be seen in the words of a participant: “You must try to eat lemon when you wake up the morning; it will be good for the digestive system.” The moderator concluded the conversation as follows: “You think that lemons are good for the digestive system. The other participants agree or disagree? Why?” Good management of group dynamics is consistent with the role of the moderator [ 16 , 19 ].

In addition, the popularity of the Internet and technology including online or Facebook can facilitate the process of focus group discussions. For example, the researcher can use online methods or Facebook to make an appointment with the participants [ 25 ]. Some studies [ 18 , 26 ] have mentioned the benefits of new approaches, such as the use of online focus groups that give individuals that are difficult to reach the ability to participate and that give researchers access to a greater variety of participants. However, there are still limitations in using technology for the elderly in terms of preparing focus groups [ 27 ]. The novice researcher should be careful about using technology with elderly sample groups because they are often limited in their ability in using the Internet and technology.

Focus group discussions with the elderly are complex and challenging for novice researchers, and a variety of skills are required when conducting a focus group. Therefore, the novice qualitative researcher needs to have confidence in the skills discussed in this paper so that he or she can obtain rigorous data. A novice researcher should also understand the strengths and limitations of a focus group discussion with the elderly, as this can have an impact on how to lead the group in order to generate quality data.

PRISMA 2009 flow diagram adapted to examine “key success of focus group discussion with the elderly for novice researchers” (adapted from Moher, Liberati, Tetzlaffand Altman [ 12 ])

Research or literature related to focus group discussions

Research on focus group discussions with the elderly

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Improving the use of focus group discussions in low income settings

Pauline f. d. scheelbeek.

1 Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK

Yashua A. Hamza

2 Childcare & Wellness Clinics, Abuja, Nigeria

Joanna Schellenberg

3 Department of Disease Control, London School of Hygiene & Tropical Medicine, London, UK

4 University College London, Institute for Global Health, London, UK

Associated Data

The datasets generated during and/or analyzed during the current study are not publicly available due to issues of confidentiality and privacy. Although respondents’ names are not included in transcripts they do include place names and any names mentioned by respondents, for example, names of Community Health Workers. Restricted and summarized data are available from the corresponding author on reasonable request.

The quality of data obtained through Focus Group Discussions (FGDs) is highly dependent on appropriate design and facilitation. In low-income settings steep power gradients between researcher and participants, as well as conversational norms, could reduce the ability of participants to voice personal opinions. Activity-oriented exercises have been suggested as a way overcoming these challenges, however little evidence exists - to date - on their use in low-income settings. We selected six exercises for use in Ethiopia and Nigeria and report our experiences.

The six exercises (picture sorting, associative pictures, picture ranking, decision trees, predictive story-telling and provocative statements) were used in 32 maternal and new-born care themed FGDs conducted in Amhara and Southern Nations Nationalities and People’s Regions (Ethiopia) and Gombe State (Nigeria). Six facilitators and two supervisors who used these exercises were interviewed about their experiences. FGD verbatim transcripts and interview notes were analysed to explore methodological effectiveness and respondents’ experience. All data were coded in NVIVO using a deductive coding frame.

Facilitators and participants described the methods as ‘fun’ and ‘enjoyable’. The exercises yielded more in-depth and complete information than ‘normal’ FGDs, but facilitator’s probing skills and overall FGD group dynamics proved crucial in this success. Explaining and conducting the exercises increased FGD length. Data richness, participant reaction and understanding, and ease of facilitation varied by study site, exercise, and participant group. Overall, the exercises worked better in Nigeria than in Ethiopia. The provocative statement exercise was most difficult for participants to understand, the decision-tree most difficult to facilitate and the picture exercises most enjoyable. The story telling exercise took relatively little time, was well understood, yielded rich data and reduced social desirability bias.

The majority of the exercises proved successful tools in yielding richer and less biased information from FGDs and were experienced as fun and engaging. Tailoring of the exercises, as well as thorough training and selection of the facilitators, were pivotal in this success. The difference in the two countries shows that adequate piloting and adaptation is crucial, and that some exercises may not be adaptable to all settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-020-01168-8.

Focus group discussions (FGDs) have been used in public health research since the 1990s [ 1 ]. They aim to explore participants’ experiences, beliefs, and attitudes by using group processes to stimulate responses and gain insights through participants exchanging views, and questioning and challenging each other [ 1 – 5 ]. They are often perceived as a cost and time efficient way of collecting information from multiple participants; and it is this efficiency, rather than their methodological strengths, that is often highlighted in the literature [ 2 ]. FGDs are commonly conducted as group interviews (hence losing the advantages that an FGD bring to data collection), with interaction between the facilitator and each participant in turn, rather than between participants [ 6 , 7 ]. As a result, the quality of the research they produce has been questioned [ 1 , 7 ].

Most of the literature on how to conduct FGDs comes from high income settings [ 7 , 8 ], and guidelines for low income settings have been criticized for focusing on practicalities, rather than on managing contextual challenges in the interactive process [ 9 ]. Challenges include steep power gradients between researcher and participants, and conversational norms, reducing the ability of participants to voice disagreements, or provide personal opinions [ 7 ]. We have used focus groups in Ghana for over 15 years, and have had difficulty making FGDs interactive, with both facilitators and participants seemingly more comfortable with group interviews. Over this time we noticed that the level of participant-participant interaction increased during activity oriented exercise, a similar experience reported by researchers in Tanzania [ 7 ].

Based on a review of the literature and our experiences in Ghana, we decided to trial the use of a variety of exercise. As well as encouraging interaction, we wanted to see if using exercises could improve the quality of our data around the drivers of behavior change. Understanding behaviors can be challenging as individuals can have difficulty explaining their own behaviors, may be unaware of some of the factors that influence their behavior, or there may be social desirability bias in reporting (e.g. [ 10 , 11 ]). These issues can lead to participants providing an unrealistic impression of their behaviors, giving superficial answers and being strongly influenced by probes [ 12 – 14 ]. Exercises may help reduce these problems by encouraging respondents to reflect on their behavior and by provoking gut reactions that uncover hidden reasons for behaviors and reduce social desirability bias. They can also focus participants on what ‘other’ people do, this may improve data quality as people are often better at explaining the behavior of others rather than their own, and because projecting their answers onto others may reduce social desirability bias [ 15 , 16 ].

Activity oriented exercise, such as sorting, story-telling and sentence completion, have been suggested as a way of improving focus groups for over two decades [ 6 ]. They are described as a means to make a group more enjoyable, increase interaction, reduce boredom, focus attention, increase reflexivity, and make sensitive topics less threatening [ 5 , 6 ]. Despite their potential advantage social scientists often rely on discussion questions, whilst exercises are more widely used in market research [ 9 ]. We found little written about the use of these exercises in low- income settings.

During the planning for a study in Ethiopia and Nigeria, we conducted a scoping literature review to identify exercises that could enhance our data collection. We searched PubMed/MEDLINE, Web of Science, Scopus, and Cochrane, screened relevant websites and expert forums for grey literature, conducted internet searches, and asked experts for relevant citations. We included literature from fields such as public health, sociology, market research, economics and criminology. We identified 36 exercises and generated a set of tables where we described each exercise, reflected on how it could be used in the study, on its advantages and disadvantages and on which biases it may help overcome. Based on these reflections we then scored each method as having high, medium or low potential for overcoming social desirability bias, improve enjoyment and yield rich in-depth data for each of the study behaviours in our study settings. These tables can be found in the supplementary files. We then met as a study team to review the tables and selected six exercises for use. This paper describes our experiences using these six methods.

The six exercises were used as part of a study on maternal and newborn care practices that explored the role that community health workers play in behaviour change [ 17 – 19 ]. The research, in Ethiopia and Nigeria, consisted of 49 interviews with recent mothers, 13 “friendship pair” interviews – in which mothers and a friend were interviewed together – and 32 FGDs with mothers, grandmothers, fathers and community health workers.

In Ethiopia, we conducted the study in four Woreda (districts) in Amhara and The Southern Nations, Nationalities and Peoples (SNNP) Regions. The Woreda were selected because they had relatively well functioning community health workers and were ‘typical’ – that is they had no unusual characteristics in terms of employment, accessibility, or population. Within each Woreda we selected a Kebele (smallest administrative division) that was reasonably accessible to the data collection team. The majority of respondents worked in agriculture and were typical for the area in terms of socio-economic class and education. The age of mothers in the FGDs ranged from 18 to 30 years old (mean = 26) and the mean reported number of children was 3.1 (range 1–7); for fathers and grandmothers age ranges were 28–45 years (mean = 36) and 36–75 years (mean = 55), with a mean reported number of children of 4 and 5 respectively. The median number of years in education was 3 for mothers and 5 for fathers, and of all interviewees 69% were Christian (predominantly Orthodox) and 31% Muslim. The interviewed community health workers had an average of 8.5 (Health Extension Workers - HEWs) and 1.9 (Health Development Army volunteers- HDAs) years of experience.

In Nigeria, we collected data from two Local Government Areas (LGAs) in Gombe State, a heterogenous state comprising multi-ethnic groups of which Fulani is the largest. One selected LGA was predominantly Christian and the other Muslim. Within each LGA, two communities were selected: the LGA headquarters and an accessible rural community that, for security reasons, would allow the researchers to be back in Gombe City before sunset. The age range of mothers in the FGDs ranged from 20 to 40 years of age (mean = 28) and the mean reported number of children was 3.9 (range 1–9); for fathers and grandmothers age ranges were 30–61 years (mean = 43) and 30–70 years (mean = 53), with a mean reported number of children of 7.7 and 5.8 respectively. Interviewees in Nigeria had usually received more years of education than those in Ethiopia: the median number of years in education was 6 for mothers and 12 for fathers. Over a third (37%) of all interviewees were Christians, whilst all others were Muslims. The interviewed frontline workers had an average of 2 (Federation of Muslim Women’s Associations in Nigeria Volunteers– FOMWANs) and 3.2 (Traditional Birth Attendants – TBAs) years of experience.

The FGD data were collected in 2015, by four interviewers in Ethiopia and six in Nigeria. The Ethiopian interviewers, 2 male and 2 female, had on average 5 years of experience in qualitative data collection and were skilled in facilitating focus group discussions. They were native speakers in the languages in which FGDs were conducted, apart from Silte, where we used translators. Cross-religious interviewing did not pose a problem, but focus groups with fathers were all conducted by male interviewers. The Nigerian interviewers, 3 male and 3 female, had varying experience in qualitative data collection (between 2 and 17 years), and were native speakers of the languages used in the FGDs. The more junior interviewers took the role of note takers, whilst the more senior interviewers facilitated the groups. Religion of facilitators and participants were matched, but interviewers facilitated FGDs with both sexes.

Facilitators and translators had 4 days of classroom training, including 2 days focusing on the activity-oriented exercises. They had 2 days of training on verbatim transcript writing, administration and data safety & confidentiality issues. During the training we explained the objectives of each exercise, reviewed the discussion guides and conducted role plays. This was followed by a two-day pilot test, where the semi-structured guides were adjusted, the exercises discussed and problems resolved. The FGDs consisted of 3–7 participants and were conducted in neutral locations such as community centres, the length of the FGDs are shown in Table  1 . Study aims were explained and written consent was obtained from each participant (or their designated proxy if the participant was illiterate) before the start of the FGDs. The development of the FGD topic guides has been described in detail elsewhere [ 17 – 19 ].

Exercise used by participant group

All FGDs were audio-recorded and transcribed by the interviewers in English within a week of data collection. During data collection, interviewers received regular feedback from senior researchers on their facilitation techniques and the use of the exercises. We also held a review meeting in the middle of data collection, to reflect on our findings and experiences and adjust data collection as needed.

Each exercise is described below along with their aims. Increasing interaction between participants was an aim of all the exercises and is not listed. The exercises aimed to be culturally acceptable, salient to participants and feasible to conduct. This included adjusting exercises where literacy was required.

Picture pile sorting

Participants were asked to work together to put seven pictures of newborn care practices into piles of those commonly practiced or not commonly practiced in their community. They were then asked to pile the same pictures into practices they felt were important or not important for the health of the baby. Finally, they were asked to pile the pictures into practices that that were promoted, or not promoted, by Community Health Workers (CHW). Facilitators probed on reasons for the classification and encouraged participants to provide details of the practices. The exercise aimed to focus the participants on the task rather than on the facilitator and increase reflexivity. Pictures for this exercise (as well as the associative picture and picture ranking exercises) were carefully selected with the help of facilitators, local government officials and community health workers. Where needed, pictures were taken in the local area to ensure they reflected the local context.

Associative pictures

Participants were shown a picture of a newborn care practice and asked to give their immediate reaction to the picture. Facilitators probed to understand the reaction. In total 5 pictures were shown. Their responses were used to facilitate further discussions within the group. By encouraging an immediate reaction, we aimed to capture the participants’ first emotions and responses to the pictures, with the aim of decreasing social desirability bias in their answers and uncovering hidden drivers of behaviour.

Picture ranking

Participants were shown pictures representing the immediate family, a neighbour and a CHW. They were asked to rank the people from most to least influential on newborn care practices. If two or more people had equal influence they could be placed next to each other. After ranking the pictures, the participants were asked about any ranking differences for specific care elements, such as bathing, feeding and thermal care. This exercise aimed to focus the participants on the task and increase reflexivity.

Decision tree (root-cause analysis)

A trunk of a tree, its main roots and sub roots were drawn on a large flipchart. The central problem was written down on the trunk of the tree. Participants were then asked to give underlying reasons for why the problem may occur. The sub roots were subsequently used to document “reasons for those reasons”. When applicable further subdivisions were made to determine the core of the problem. The exercise aimed to yield in-depth answers for complex questions by triggering the participants’ cognitive skills and encouraging them to think in a more comprehensive and reflexive way about the problem presented.

Predictive story telling

The facilitator read a fictitious, but realistic, story that needed to be finished by the participants. The story explored a dilemma new mothers may face when receiving conflicting advice from family members and community health workers. Once the first part of the story was completed, participants were given some new information and asked to say what would happen next. The exercise aimed to reduce embarrassment and social desirability bias, as participants can give their answers in the third person (i.e. as if they are talking about the fictitious person) whilst reflecting on their own practices.

Provocative statements (Q-statements)

A series of controversial statements were read out to the participants, who were encouraged to respond as soon as the facilitator finished the statement. As for the associative picture exercise, this exercise aimed to capture gut reactions, to reduce social desirability bias and uncover hidden drivers of behaviours.

The exercises described above were used in FGDs with mothers, grandmothers, fathers and community health workers. Each respondent group had a specially designed interview guide that included 3–4 of the selected methods as shown in Table ​ Table1 1 .

Our experiences with the exercises were evaluated in three ways: Interviews with and reflections of senior researchers who observed 16 of the 40 pilot and actual FGDs, and who supervised the data collectors; skype or phone interviews with eight of the 10 data collectors about their experiences and views on the exercises; and a review of all the FGD transcripts to explore how well the methods worked and how the respondents reacted to them. The skype or phone interviews were conducted in 2015, 4 months after the completion of data collection. Interviews were conducted in English by one of us (PS) using a semi structured guide which asked about overall impression of the exercises in the FGDs, advantages and disadvantages of each exercise, as well the ability of the exercise to reach its objective, such as yielding rich and valid data, overcoming social desirability bias, participant engagement, and enjoyment of the exercises for participants and facilitator. Furthermore, facilitators were asked whether they had any recommendations for improvement for each of the exercises. (Supplementary Files) Notes were taken during the interviews, which were written up as expanded notes immediately after the interview.

Data analysis was conducted by PS and ZH who met regularly during the analysis process to discuss the coding and emerging themes. Analysis started with multiple readings of the expanded notes and FGD transcripts to ensure familiarity. Analysis was conducted in Nvivo with nodes for each exercise, and was both deductive and inductive. The deductive themes were: data quality (sub themes were data depth/richness, interactions between participants and impact on social desirability bias); feasibility (sub themes were ease of facilitation, participant comprehension and impact on FGD length) and participant reaction (sub themes enjoyment).

Analysis of the FGD transcripts included coding all participant comments on the methods (e.g. we are enjoying this, I don’t understand this, this is taking too long) and any other reactions (e.g. laughter, silence, confusion, enthusiasm, distraction). For the sub-theme data depth/richness we coded examples of the length and depth of responses and for impact on social desirability bias examples of guarded responses, frank/open responses and any statement where respondents were critical or the services they had received. To put these findings in context we generated memos for each FGD on the overall group dynamics, the facilitators skills in probing and managing the group and anything that seemed to make a method work well or nor so well.

The skype or phone interviews and the FGDs were analyzed separately and the main themes and findings were then compared. This was bi-directional as we explored whether the findings from the interviews with study staff were reflected in the FGD data (e.g. if the staff said a method was challenging for participants could we see evidence of this in the FGD transcripts) as well as exploring if the study staff interviews could explain the results of the FGD analysis (e.g. if a method garnered very rich FGD data could the staff interviews help understand why?). This resulted in a set of final themes that reflected both the interview and the FGD transcript data.

The final coding tree was similar to the initial deductive themes that are described above. Inductive sub-themes emerged under ‘feasibility’ relating to issues of data processing (e.g. note taking, transcription and translation) and the constraints of physical space; and for ‘participant reaction’ relating to distraction and emotional responses. Below we present our overarching findings on the exercises followed by exercise-specific findings.

The facilitators felt that the exercises yielded more in-depth and complete information than the ‘normal’ FGDs they were used to. This was echoed by the principal investigator (ZH) who found the FGDs more discursive, and less of a group interview, than previous FGDs in the study settings. Both facilitators and participants describe the methods as ‘ fun’ and ‘ enjoyable’ :

‘Some of the participants we selected for the in-depth interviews [with no “exercises”] came out very disappointed: they heard from friends that it was something fun with pictures and drawings, but in their own interview only “normal” questions were asked’ [FGD facilitator- Nigeria] .

Data richness, participant reaction and ease of facilitation varied by study site, exercise, and to a lesser extent participant group. In relation to study site, overall the methods worked better in Nigeria than in Ethiopia, as they were better understood. The facilitators felt that participants were more open and interacted with each other more than in Ethiopia. This was also true for the non-exercise elements of the FGDs.

In both sites there was evidence of social desirability bias, which varied by FGD. Some FGDs resulted in frank and illuminating discussions and others in guarded and short responses – unsurprisingly the exercises worked best in the more open FGDs. Facilitators put the variation down to group dynamics, for example, the presence of a domineering and judgemental participant in one FGD appeared to stop participants opening up, while in another FGD a very open participant shared a personal story which prompted others in the group to be more open. As well as group dynamics, the depth of the data was linked to the ability of the facilitator to probe effectively without turning the FGD into a group interview.

The number of exercises used in the FGDs was relatively high (3–4), and took longer than we had anticipated, particularly in Ethiopia. Some facilitators felt that this was too many, and caused exhaustion towards the end of the FGDs for both participants and facilitators. We had many examples of participants having to leave, asking when the FGD would end and being distracted.

Respondent 2: Ar e we not going? Facilitator: We are only left with two questions. Respondent 2: In Christ’s sake Respondent 3: It is getting late [Mother FGD- Ethiopia]

Using the same methods across respondent groups, allowed us to compare and contrast findings.

On a practical level the note-takers and transcribers experienced difficulties in capturing the discussion when the exercises yielded excitement or heated discussion as multiple participants often talked at the same time or in quick succession. Where translators were used valuable discussions that occurred while exercises were being conducted were lost.

Our findings for each method are presented below and are summarized in Table  2 .

Identified themes and positive, mixed and negative experiences in exercises used by participant group

Associative picture, ranking & sorting exercises

The pictures were often greeted by participants with enthusiasm, and sometimes an emotional response: ‘poor woman … . ’ or ‘it [picture] gives me joy’ ; and participants enjoyed the exercises:

Facilitator: Okay, thank you, we will revisit some of these discussions later, but let me gather these pictures. Respondents: All clap. Respondent 1: We are enjoying this, we like this discussion with the pictures [clapping continues] [Grandmother FGD Nigeria].

Despite this enthusiasm the exercises were not always easily understood, and facilitators sometimes explained the exercise multiple times, had to reorient discussions, or had to sort or rank the pictures themselves using multiple prompts ‘who is the next influential … … and then who’ . This added to the length of the FGDs. Although there were some comprehension problems in Nigeria: ‘Can you explain it to us again’, these were significantly less than in Ethiopia. This is reflected in a greater facilitator- participant interaction during the exercises in Ethiopia, compared to greater participant-participant interaction in Nigeria.

The facilitators themselves described the exercises as ‘hit and miss’ , particularly the associative picture exercise, but felt they were a useful starting off exercise:

‘ Excitement in this round did not always lead to useful discussions [ … ] and quality of answers, but gave an initial overview. This is a great exercise at the beginning, as it could serve as some sort of ice-breaker. Or it could come back at several points during the interview to re-energise the participants’ [Facilitator Nigeria].

Overall these exercises yielded useful information about behaviours that were practiced, beliefs about these behaviours, advice given about the behaviours and key influencers. The level of discussion was linked to whether the topic of the picture was of a new or unusual behaviour, or whether there were variations in opinions about the practice of the behaviour. For example, the first quote below is for wrapping the baby after delivery, this is a widely accepted behaviour with little variation in beliefs. The second quote relates to skin to skin care, a new practice, where discussions of the topic were livelier and in depth. A lack of discussion did not mean the exercise did not work well, as it told us something about the normality of the behaviour:

Facilitator: Let me show you another picture. It shows a baby being wrapped after delivery. [ … ] What do you think about this? Participant 1: It is good Participant 2: It is good

All respondents (mothers) upon seeing a skin-to-skin picture: It is not practised! [laughter] Respondent 1: Are they naked? Facilitator: Yes. Respondent 1: [laughs] Respondent 2: [looks surprised by the picture] Respondent 1: We don’t see such thing before … ...

It was essential that the facilitator explained the picture before starting the exercise. Otherwise discussions deviated into the details of the picture, such as whether the person was from their ethnic group, was the baby circumcised, or that the mother looked tired. Another problem was our initial use of too many, and too similar, sorting and ranking exercises. This led to repetition in content, which frustrated the participants:

‘Respondent 1: We have already discussed on it. You are asking repeatedly. Facilitator: It is not a repeated question. Earlier we have discussed on the most important and less important behaviours. Now I am asking you about what the Health workers promote and encourage you to do and do not’ [Mother FGD- Ethiopia].

Other issues that came up less frequently were participants believing that we were looking for the correct answer rather than an opinion; a lack of space making the sorting and ranking difficult to do; and poor eyesight in the older respondents meaning that pictures in the associative picture exercise needed to be passed around rather than held up, which added substantially to the time the FGD took.

The root cause analysis was described by all facilitators as useful, but challenging. Overall, they provided rich information on the problems they explored, especially in the FGDs where the participants were open and felt able to be critical. In these cases, participants were eager to share their opinions and knowledge:

‘Facilitator: What are the reasons why women do not go and deliver at the health facility as desired? Respondent 1: Here I am [raises hand eagerly] Respondent 2: Here I am too, I have much to say [raises hand]. Facilitator: “ Good! Let us get the main reasons’ [community health workers FGD- Nigeria].

The depth of data was also linked to whether the participants perceived that the chosen topic was a problem – probably linked to their openness. For example, in one FGD participants repeatedly said there was no problem and all was being done well, yet in a second FGD participants shared their personal experiences of the problem, which provided insightful and rich data.

Not all participants understood the symbolic meaning of the tree trunk and the roots, and from the transcripts it appears that the drawings were not always used. Facilitators reported that writing the reasons for the problem on the tree root helped to structure the participants’ thoughts and deepen out emerging issue. Writing down the participants’ reasons was difficult for illiterate participants, and the facilitators tried to overcome this by reading the labels out loud and summarizing them every now and then.

Facilitators found it challenging to process all information to make an adequate and informative root diagram on the spot, especially as participants often gave answers in an unstructured manner. The exercise was regarded as the most demanding for facilitators, requiring a high level of analytical skills. Furthermore, some facilitators suggested that the tool worked better with more educated participants, such as the community health workers, who themselves had better analytic skills.

Predictive storytelling

Participants identified with the character and the situation in the story, and answered questions as if the character was living in their village. Some facilitators opened the story as if telling a folk tale which participants liked. With the help of facilitator probes the scenarios generated discussions and uncovered insights such as how families manage conflicting advice, and the level of trust in community health workers: “We were able to get interesting information on mechanisms of change. There were arguments for both sides of the story and they explored several scenarios” [Facilitator- Ethiopia]. The method was relatively quick to do in relation to the quantity of data captured.

Facilitators felt that focusing on a character reduced social desirability bias. For example, participants said the character may behave at odds with expected behavior, but then stressed that they themselves would behave differently: ‘She will listen to her sister’s advice, but as for me it is better if she follows the health worker advice’ [Mother FGD Ethiopia]. In most FGDs participants switched between the third and first person when talking about the scenarios, with the first person used to present a strong belief about a behavior, or to reflect on what they would do differently to the character: ‘NO … NO … NO … … . I do not want to do it like this’ [Grandmother FGD Ethiopia].

In Ethiopia participants frequently reported what the character ‘should’ do, rather than on what they ‘ would’ do. Answers tended to be shorter and less complex than in Nigeria, where discussions were often lively, humorous and more open:

‘Respondent 3: Her mother has right over her … she will follow the mother’s advice, she will be afraid of God’s wrath Respondent 2: but some Ladis [character] will not behave like this, the Ladi of nowadays [laughter], the rude Ladis of nowadays, who will look into our eyeballs and tell us that the doctors have told them this and that [imitating Ladi and shaking her body – everyone laughs] Respondent 1: They will not keep quiet and listen’ [Grandmother FGD Nigeria]

The switching between the first and the third persona, and between should and would, was an entry point for facilitator probes.

Provocative statements

The use of statements was often poorly understood by participants, but the exercise did work once participants understood the task. The exercise elicited some useful information, for example it uncovered differences in perceptions of volunteer workers compared to paid community workers, recent changes in who influences behaviors and it allowed us to gauge the strength of people’s opinions. The method did not always yield immediate gut reactions, but there were some successes- particularly in Nigeria: ‘People literally jumped up to give their answers – I had the feeling they really told me their gut feeling, the first thing that came to mind’ [ Facilitator- Nigeria].

Provocative statements worked best where there was a clear understanding that this was a statement to discuss, and not a fact or the facilitators view. It was the method that participants asked the facilitator to explain again most often, and where participants sometimes remained in silence: ‘This topic is difficult for us, please clarify’ [Community health worker FGD, Nigeria]. This occurred despite facilitators conducting practice rounds with humorous examples. The lack of understanding was attributed to confusion between a statement and someone’s opinion: ‘They see an “authoritative” figure and confuse the statement for their opinion. Sometimes they even said, “Is that really true?” whereas it was meant to be provocative’ [Facilitator- Ethiopia]. Faced with silence or confusion the facilitators had to explain the exercise again or rephrase the statement as a ‘normal’ question: ‘On many occasions, we had to convert Q-statements to questions. I think it is more a cultural thing: people are just not used to being confronted by provocative questions. It is either you are asking them a question, or you are telling them something’ [Facilitator-Ethiopia] .

Short and focused provocative statements were most suitable in both sites as they were easier to understand. We encountered some problems with translation and with the use of translators. The provocative statements were originally written in English and translated in Amharic and Hausa. For most statements, this did not pose any difficulties, but some statements were difficult to translate. This resulted in long descriptive read outs that were not suitable for use. In these cases, we developed alternative statements written directly in the local language. Where we used translators during the FGD we trained them around the use of provocative statements, but we still encountered problems: ‘The translator had difficulties in interpreting the statements properly, resulting in very long statements, that did not provoke any immediate response’ [Facilitator- Ethiopia].

The provocative statements were done at the end of the FGDs, and the depth and usefulness of responses was linked to how lively the participants were at the point, and whether they perceived that they had provided similar answers previously.

There was agreement across fieldworkers, supervisors and senior investigators that the exercises improved interaction between participants, enhanced data quality, and made the FGDs more enjoyable compared to previous experiences in the settings. We did not encounter a limitation identified in the literature of participants not liking the idea of playing ‘games’ or thinking the researchers were strange [ 5 , 6 ].

The methods were more successful in Nigeria than Ethiopia: this may be related to cultural differences in conversational norms and issues of positionality between facilitator and participants, exemplified by an Ethiopian facilitator describing that participants saw them as an ‘ authoritative figure’ . The potential for high levels of social desirability bias has been noted for Ethiopia given the political and cultural context [ 20 ], and although we found evidence that social desirability bias remained we found that some techniques reduced it, with the story telling approach for example allowing a projection of responses onto an ‘other’. In Ethiopia in-depth ethnographic methods could be a more useful tool to overcoming such bias than FGDs.

A strong influence of positionality on participants was also found in Tanzania, where exercises reduced its impact as participants focused less on the facilitator, with the best FGDs occurring when the facilitator removed themselves from the process altogether [ 7 ]. Given the importance of probes for generating rich data in our study, and in other studies in similar settings [ 21 ], we would not recommend the removal of the facilitator, but our findings highlight the importance of the selection and training of data collectors, and in-depth thinking about how they present themselves to the participants. We found that key to success of the exercises was, whether the facilitators had fully understood the aims and objectives of the discussions, mastered the content and process of the exercises and knew how to probe effectively. Some of the Nigerian FGDs were facilitated by one of the senior researchers (YH), and the impact on data quality of their greater experience in encouraging interaction between participants and their gentle but effective probing was clearly visible.

The predictive story telling was one of the most successful methods it was well understood, enjoyed by participants and facilitator, generated interaction and its projective nature seems to have gone some way to address social desirability bias. We found one study that reported on the use of stories in a low-income setting, albeit in in-depth interviews [ 21 ]. They also concluded that the method had been successful and increased the quality of their data, but faced the same challenge of respondents often reporting what should be done rather than what the character in the story would have done. We discovered that in some languages the differences between should and would were also difficult to translate. We think that one of the reasons the story was successful was because it was carefully tailored to the cultural context and resonated with the participants.

The provocative statements worked the least well with comprehension issues in both sites- despite facilitators using humorous examples. This meant that facilitators spent time explaining the exercise, lengthening the FGDs, and in Ethiopia facilitators often had to rephrase the statements as questions. We also found issues of translation and of using translators particularly problematic for this method, with statements written directly in the local language working best. Language issues are a common problem in FGDs in low income settings with the use of translators having a negative impact on group interaction and discussion, and where at all possible they should not be used [ 8 ].

We felt that the number of methods included in the FGDs and repetition of content hindered their effectiveness by making the FGDs too long and at times frustrating for the participant. Although the exercises were described as fun, towards the end of the FGDs participants were often anxious to leave. In Ethiopia the need to explain the exercises multiple times and the use of translators meant the FGDs were longer than we would have hoped. There is no recommendation on the number of exercises that should be included in FGDs, but the numbers should be influenced by the impact they have on the length of the FGDs, participants’ age and ability to express themselves [ 6 ].

This is – to our knowledge – the first study reporting on experience with a range of activity-oriented exercises in low-income settings. The study was however subject to some limitations. First, data collection focused on maternal and child care behaviors and the findings may not be transferable to studies accessing other types of behaviors. Second, participants were not asked directly about their opinion and experiences of participating in the FGDs, rather conclusions were drawn from transcripts. Third, the time and scope of the research did not allow for exploration of other methods and exercises beyond the six evaluated in this study: there are several other promising methods that should be explored for use in low-income settings. Finally, interviews with facilitators occurred by phone and skype, after completion of the FGD work in both countries and were conducted by a researcher who had supervised data collection rather than someone external to the study team.

Conclusions

The majority of our exercises– and in particular story-telling - proved successful tools in yielding rich and less biased information from FGDs. Participants and facilitators experienced the exercises as fun: they improved participation and engagement. However, the exercises adversely affected the length of the FGDs and in future we would use fewer exercises. Given the differences we noted between the two study sites, we recommend that all exercises are adequately piloted and adapted, or not used at all if they do not improve quality.

Acknowledgements

Not applicable.

Abbreviations

Authors’ contributions.

ZH, PS & YH developed the research concept, PS, ZH & YH developed the research methodology, PS & YH collected the data, PS & ZH analyzed and interpreted the data, PS & ZH wrote the manuscript, JS & YH commented on drafts of the manuscript. All authors read and approved the final manuscript.

The study was funded by the Bill and Melinda Gates foundation as part of the IDEAS study. Grant number OPP1017031. The funders had no role in the study design, data collection, analysis, interpretation or write up of the manuscript.

Availability of data and materials

Ethics approval and consent to participate.

Study protocols were reviewed and approved by the London School of Hygiene & Tropical Medicine Ethics Committee, the Ministry of Science and Technology in Ethiopia, the National Research Ethics Committee in Nigeria and the Gombe State Government in Nigeria. Written consent was obtained from all participants; illiterate participants were asked to appoint a proxy to sign on their behalf. A copy of the consent forms can be found in the supplementary files.

All data were anonymized for publication.

Consent for publication

Competing interests.

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

• Open access
• Published: 19 April 2024

Person-centered care assessment tool with a focus on quality healthcare: a systematic review of psychometric properties

• Lluna Maria Bru-Luna 1 ,
• Manuel Martí-Vilar 2 ,
• César Merino-Soto 3 ,
• José Livia-Segovia 4 ,
• Juan Garduño-Espinosa 5 &
• Filiberto Toledano-Toledano 5 , 6 , 7  

BMC Psychology volume  12 , Article number:  217 ( 2024 ) Cite this article

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The person-centered care (PCC) approach plays a fundamental role in ensuring quality healthcare. The Person-Centered Care Assessment Tool (P-CAT) is one of the shortest and simplest tools currently available for measuring PCC. The objective of this study was to conduct a systematic review of the evidence in validation studies of the P-CAT, taking the “Standards” as a frame of reference.

First, a systematic literature review was conducted following the PRISMA method. Second, a systematic descriptive literature review of validity tests was conducted following the “Standards” framework. The search strategy and information sources were obtained from the Cochrane, Web of Science (WoS), Scopus and PubMed databases. With regard to the eligibility criteria and selection process, a protocol was registered in PROSPERO (CRD42022335866), and articles had to meet criteria for inclusion in the systematic review.

A total of seven articles were included. Empirical evidence indicates that these validations offer a high number of sources related to test content, internal structure for dimensionality and internal consistency. A moderate number of sources pertain to internal structure in terms of test-retest reliability and the relationship with other variables. There is little evidence of response processes, internal structure in measurement invariance terms, and test consequences.

The various validations of the P-CAT are not framed in a structured, valid, theory-based procedural framework like the “Standards” are. This can affect clinical practice because people’s health may depend on it. The findings of this study show that validation studies continue to focus on the types of validity traditionally studied and overlook interpretation of the scores in terms of their intended use.

Peer Review reports

Person-centered care (PCC)

Quality care for people with chronic diseases, functional limitations, or both has become one of the main objectives of medical and care services. The person-centered care (PCC) approach is an essential element not only in achieving this goal but also in providing high-quality health maintenance and medical care [ 1 , 2 , 3 ]. In addition to guaranteeing human rights, PCC provides numerous benefits to both the recipient and the provider [ 4 , 5 ]. Additionally, PCC includes a set of necessary competencies for healthcare professionals to address ongoing challenges in this area [ 6 ]. PCC includes the following elements [ 7 ]: an individualized, goal-oriented care plan based on individuals’ preferences; an ongoing review of the plan and the individual’s goals; support from an interprofessional team; active coordination among all medical and care providers and support services; ongoing information exchange, education and training for providers; and quality improvement through feedback from the individual and caregivers.

There is currently a growing body of literature on the application of PCC. A good example of this is McCormack’s widely known mid-range theory [ 8 ], an internationally recognized theoretical framework for PCC and how it is operationalized in practice. This framework forms a guide for care practitioners and researchers in hospital settings. This framework is elaborated in PCC and conceived of as “an approach to practice that is established through the formation and fostering of therapeutic relationships between all care providers, service users, and others significant to them, underpinned by values of respect for persons, [the] individual right to self-determination, mutual respect, and understanding” [ 9 ].

Thus, as established by PCC, it is important to emphasize that reference to the person who is the focus of care refers not only to the recipient but also to everyone involved in a care interaction [ 10 , 11 ]. PCC ensures that professionals are trained in relevant skills and methodology since, as discussed above, carers are among the agents who have the greatest impact on the quality of life of the person in need of care [ 12 , 13 , 14 ]. Furthermore, due to the high burden of caregiving, it is essential to account for caregivers’ well-being. In this regard, studies on professional caregivers are beginning to suggest that the provision of PCC can produce multiple benefits for both the care recipient and the caregiver [ 15 ].

Despite a considerable body of literature and the frequent inclusion of the term in health policy and research [ 16 ], PCC involves several complications. There is no standard consensus on the definition of this concept [ 17 ], which includes problematic areas such as efficacy assessment [ 18 , 19 ]. In addition, the difficulty of measuring the subjectivity involved in identifying the dimensions of the CPC and the infrequent use of standardized measures are acute issues [ 20 ]. These limitations and purposes motivated the creation of the Person-Centered Care Assessment Tool (P-CAT; [ 21 ]), which emerged from the need for a brief, economical, easily applied, versatile and comprehensive assessment instrument to provide valid and reliable measures of PCC for research purposes [ 21 ].

Person-centered care assessment tool (P-CAT)

There are several instruments that can measure PCC from different perspectives (i.e., the caregiver or the care recipient) and in different contexts (e.g., hospitals and nursing homes). However, from a practical point of view, the P-CAT is one of the shortest and simplest tools and contains all the essential elements of PCC described in the literature. It was developed in Australia to measure the approach of long-term residential settings to older people with dementia, although it is increasingly used in other healthcare settings, such as oncology units [ 22 ] and psychiatric hospitals [ 23 ].

Due to the brevity and simplicity of its application, the versatility of its use in different medical and care contexts, and its potential emic characteristics (i.e., constructs that can be cross-culturally applicable with reasonable and similar structure and interpretation; [ 24 ]), the P-CAT is one of the most widely used tests by professionals to measure PCC [ 25 , 26 ]. It has expanded to several countries with cultural and linguistic differences. Since its creation, it has been adapted in countries separated by wide cultural and linguistic differences, such as Norway [ 27 ], Sweden [ 28 ], China [ 29 ], South Korea [ 30 ], Spain [ 25 ], and Italy [ 31 ].

The P-CAT comprises 13 items rated on a 5-point ordinal scale (from “strongly disagree” to “strongly agree”), with high scores indicating a high degree of person-centeredness. The scale consists of three dimensions: person-centered care (7 items), organizational support (4 items) and environmental accessibility (2 items). In the original study ( n  = 220; [ 21 ]), the internal consistency of the instrument yielded satisfactory values for the total scale ( α  = 0.84) and good test-retest reliability ( r  =.66) at one-week intervals. A reliability generalization study conducted in 2021 [ 32 ] that estimated the internal consistency of the P-CAT and analyzed possible factors that could affect the it revealed that the mean α value for the 25 meta-analysis samples (some of which were part of the validations included in this study) was 0.81, and the only variable that had a statistically significant relationship with the reliability coefficient was the mean age of the sample. With respect to internal structure validity, three factors (56% of the total variance) were obtained, and content validity was assessed by experts, literature reviews and stakeholders [ 33 ].

Although not explicitly stated, the apparent commonality between validation studies of different versions of the P-CAT may be influenced by an influential decades-old validity framework that differentiates three categories: content validity, construct validity, and criterion validity [ 34 , 35 ]. However, a reformulation of the validity of the P-CAT within a modern framework, which would provide a different definition of validity, has not been performed.

Scale validity

Traditionally, validation is a process focused on the psychometric properties of a measurement instrument [ 36 ]. In the early 20th century, with the frequent use of standardized measurement tests in education and psychology, two definitions emerged: the first defined validity as the degree to which a test measures what it intends to measure, while the second described the validity of an instrument in terms of the correlation it presents with a variable [ 35 ].

However, in the past century, validity theory has evolved, leading to the understanding that validity should be based on specific interpretations for an intended purpose. It should not be limited to empirically obtained psychometric properties but should also be supported by the theory underlying the construct measured. Thus, to speak of classical or modern validity theory suggests an evolution in the classical or modern understanding of the concept of validity. Therefore, a classical approach (called classical test theory, CTT) is specifically differentiated from a modern approach. In general, recent concepts associated with a modern view of validity are based on (a) a unitary conception of validity and (b) validity judgments based on inferences and interpretations of the scores of a measure [ 37 , 38 ]. This conceptual advance in the concept of validity led to the creation of a guiding framework to for obtaining evidence to support the use and interpretation of the scores obtained by a measure [ 39 ].

This purpose is addressed by the Standards for Educational and Psychological Testing (“Standards”), a guide created by the American Educational Research Association (AERA), the American Psychological Association (APA) and the National Council on Measurement in Education (NCME) in 2014 with the aim of providing guidelines to assess the validity of the interpretations of scores of an instrument based on their intended use. Two conceptual aspects stand out in this modern view of validity: first, validity is a unitary concept centered on the construct; second, validity is defined as “the degree to which evidence and theory support the interpretations of test scores for proposed uses of tests” [ 37 ]. Thus, the “Standards” propose several sources that serve as a reference for assessing different aspects of validity. The five sources of valid evidence are as follows [ 37 ]: test content, response processes, internal structure, relations to other variables and consequences of testing. According to AERA et al. [ 37 ], test content validity refers to the relationship of the administration process, subject matter, wording and format of test items to the construct they are intended to measure. It is measured predominantly with qualitative methods but without excluding quantitative approaches. The validity of the responses is based on analysis of the cognitive processes and interpretation of the items by respondents and is measured with qualitative methods. Internal structure validity is based on the interrelationship between the items and the construct and is measured by quantitative methods. Validity in terms of the relationship with other variables is based on comparison between the variable that the instrument intends to measure and other theoretically relevant external variables and is measured by quantitative methods. Finally, validity based on the results of the test analyses consequences, both intended and unintended, that may be due to a source of invalidity. It is measured mainly by qualitative methods.

Thus, although validity plays a fundamental role in providing a strong scientific basis for interpretations of test scores, validation studies in the health field have traditionally focused on content validity, criterion validity and construct validity and have overlooked the interpretation and use of scores [ 34 ].

“Standards” are considered a suitable validity theory-based procedural framework for reviewing the validity of questionnaires due to its ability to analyze sources of validity from both qualitative and quantitative approaches and its evidence-based method [ 35 ]. Nevertheless, due to a lack of knowledge or the lack of a systematic description protocol, very few instruments to date have been reviewed within the framework of the “Standards” [ 39 ].

Current study

Although the P-CAT is one of the most widely used instruments by professionals and has seven validations [ 25 , 27 , 28 , 29 , 30 , 31 , 40 ], no analysis has been conducted of its validity within the framework of the “Standards”. That is, empirical evidence of the validity of the P-CAT has not been obtained in a way that helps to develop a judgment based on a synthesis of the available information.

A review of this type is critical given that some methodological issues seem to have not been resolved in the P-CAT. For example, although the multidimensionality of the P-CAT was identified in the study that introduced it, Bru-Luna et al. [ 32 ] recently stated that in adaptations of the P-CAT [ 25 , 27 , 28 , 29 , 30 , 40 ], the total score is used for interpretation and multidimensionality is disregarded. Thus, the multidimensionality of the original study was apparently not replicated. Bru-Luna et al. [ 32 ] also indicated that the internal structure validity of the P-CAT is usually underreported due to a lack of sufficiently rigorous approaches to establish with certainty how its scores are calculated.

The validity of the P-CAT, specifically its internal structure, appears to be unresolved. Nevertheless, substantive research and professional practice point to this measure as relevant to assessing PCC. This perception is contestable and judgment-based and may not be sufficient to assess the validity of the P-CAT from a cumulative and synthetic angle based on preceding validation studies. An adequate assessment of validity requires a model to conceptualize validity followed by a review of previous studies of the validity of the P-CAT using this model.

Therefore, the main purpose of this study was to conduct a systematic review of the evidence provided by P-CAT validation studies while taking the “Standards” as a framework.

The present study comprises two distinct but interconnected procedures. First, a systematic literature review was conducted following the PRISMA method ( [ 41 ]; Additional file 1; Additional file 2) with the aim of collecting all validations of the P-CAT that have been developed. Second, a systematic description of the validity evidence for each of the P-CAT validations found in the systematic review was developed following the “Standards” framework [ 37 ]. The work of Hawkins et al. [ 39 ], the first study to review validity sources according to the guidelines proposed by the “Standards”, was also used as a reference. Both provided conceptual and pragmatic guidance for organizing and classifying validity evidence for the P-CAT.

The procedure conducted in the systematic review is described below, followed by the procedure for examining the validity studies.

Systematic review

Search strategy and information sources.

Initially, the Cochrane database was searched with the aim of identifying systematic reviews of the P-CAT. When no such reviews were found, subsequent preliminary searches were performed in the Web of Science (WoS), Scopus and PubMed databases. These databases play a fundamental role in recent scientific literature since they are the main sources of published articles that undergo high-quality content and editorial review processes [ 42 ]. The search formula was as follows. The original P-CAT article [ 21 ] was located, after which all articles that cited it through 2021 were identified and analyzed. This approach ensured the inclusion of all validations. No articles were excluded on the basis of language to avoid language bias [ 43 ]. Moreover, to reduce the effects of publication bias, a complementary search in Google Scholar was also performed to allow the inclusion of “gray” literature [ 44 ]. Finally, a manual search was performed through a review of the references of the included articles to identify other articles that met the search criteria but were not present in any of the aforementioned databases.

This process was conducted by one of the authors and corroborated by another using the Covidence tool [ 45 ]. A third author was consulted in case of doubt.

Eligibility criteria and selection process

The protocol was registered in PROSPERO, and the search was conducted according to these criteria. The identification code is CRD42022335866.

The articles had to meet the following criteria for inclusion in the systematic review: (a) a methodological approach to P-CAT validations, (b) an experimental or quasiexperimental studies, (c) studies with any type of sample, and (d) studies in any language. We discarded studies that met at least one of the following exclusion criteria: (a) systematic reviews or bibliometric reviews of the instrument or meta-analyses or (b) studies published after 2021.

Data collection process

After the articles were selected, the most relevant information was extracted from each article. Fundamental data were recorded in an Excel spreadsheet for each of the sections: introduction, methodology, results and discussion. Information was also recorded about the limitations mentioned in each article as well as the practical implications and suggestions for future research.

Given the aim of the study, information was collected about the sources of validity of each study, including test content (judges’ evaluation, literature review and translation), response processes, internal structure (factor analysis, design, estimator, factor extraction method, factors and items, interfactor R, internal replication, effect of the method, and factor loadings), and relationships with other variables (convergent, divergent, concurrent and predictive validity) and consequences of measurement.

Description of the validity study

To assess the validity of the studies, an Excel table was used. Information was recorded for the seven articles included in the systematic review. The data were extracted directly from the texts of the articles and included information about the authors, the year of publication, the country where each P-CAT validation was produced and each of the five standards proposed in the “Standards” [ 37 ].

The validity source related to internal structure was divided into three sections to record information about dimensionality (e.g., factor analysis, design, estimator, factor extraction method, factors and items, interfactor R, internal replication, effect of the method, and factor loadings), reliability expression (i.e., internal consistency and test-retest) and the study of factorial invariance according to the groups into which it was divided (e.g., sex, age, profession) and the level of study (i.e., metric, intercepts). This approach allowed much more information to be obtained than relying solely on source validity based on internal structure. This division was performed by the same researcher who performed the previous processes.

Study selection and study characteristics

The systematic review process was developed according to the PRISMA methodology [ 41 ].

The WoS, Scopus, PubMed and Google Scholar databases were searched on February 12, 2022 and yielded a total of 485 articles. Of these, 111 were found in WoS, 114 in Scopus, 43 in PubMed and 217 in Google Scholar. In the first phase, the title and abstracts of all the articles were read. In this first screening, 457 articles were eliminated because they did not include studies with a methodological approach to P-CAT validation and one article was excluded because it was the original P-CAT article. This resulted in a total of 27 articles, 19 of which were duplicated in different databases and, in the case of Google Scholar, within the same database. This process yielded a total of eight articles that were evaluated for eligibility by a complete reading of the text. In this step, one of the articles was excluded due to a lack of access to the full text of the study [ 31 ] (although the original manuscript was found, it was impossible to access the complete content; in addition, the authors of the manuscript were contacted, but no reply was received). Finally, a manual search was performed by reviewing the references of the seven studies, but none were considered suitable for inclusion. Thus, the review was conducted with a total of seven articles.

Of the seven studies, six were original validations in other languages. These included Norwegian [ 27 ], Swedish [ 28 ], Chinese (which has two validations [ 29 , 40 ]), Spanish [ 25 ], and Korean [ 30 ]. The study by Selan et al. [ 46 ] included a modification of the Swedish version of the P-CAT and explored the psychometric properties of both versions (i.e., the original Swedish version and the modified version).

The item selection and screening process are illustrated in detail in Fig.  1 .

PRISMA 2020 flow diagram for new systematic reviews including database searches

Validity analysis

To provide a clear overview of the validity analyses, Table  1 descriptively shows the percentages of items that provide information about the five standards proposed by the “Standards” guide [ 37 ].

The table shows a high number of validity sources related to test content and internal structure in relation to dimensionality and internal consistency, followed by a moderate number of sources for test-retest and relationship with other variables. A rate of 0% is observed for validity sources related to response processes, invariance and test consequences. Below, different sections related to each of the standards are shown, and the information is presented in more detail.

Evidence based on test content

The first standard, which focused on test content, was met for all items (100%). Translation, which refers to the equivalence of content between the original language and the target language, was met in the six articles that conducted validation in another language and/or culture. These studies reported that the validations were translated by bilingual experts and/or experts in the area of care. In addition, three studies [ 25 , 29 , 40 ] reported that the translation process followed International Test Commission guidelines, such as those of Beaton et al. [ 47 ], Guillemin [ 48 ], Hambleton et al. [ 49 ], and Muñiz et al. [ 50 ]. Evaluation by judges, who referred to the relevance, clarity and importance of the content, was divided into two categories: expert evaluation (a panel of expert judges for each of the areas to consider in the evaluation instrument) and experiential evaluation (potential participants testing the test). The first type of evaluation occurred in three of the articles [ 28 , 29 , 46 ], while the other occurred in two [ 25 , 40 ]. Only one of the items [ 29 ] reported that the scale contained items that reflected the dimension described in the literature. The validity evidence related to the test content presented in each article can be found in Table  2 .

Evidence based on response processes

The second standard, related to the validity of the response process, was obtained according to the “Standards” from the analysis of individual responses: “questioning test takers about their performance strategies or response to particular items (…), maintaining records that monitor the development of a response to a writing task (…), documentation of other aspects of performance, like eye movement or response times…” [ 37 ] (p. 15). According to the analysis of the validity of the response processes, none of the articles complied with this evidence.

Evidence based on internal structure

The third standard, validity related to internal structure, was divided into three sections. First, the dimensionality of each study was examined in terms of factor analysis, design, estimator, factor extraction method, factors and items, interfactor R, internal replication, effect of the method, and factor loadings. Le et al. [ 40 ] conducted an exploratory-confirmatory design while Sjögren et al. [ 28 ] conducted a confirmatory-exploratory design to assess construct validity using confirmatory factor analysis (CFA) and investigated it further using exploratory factor analysis (EFA). The remaining articles employed only a single form of factor analysis: three employed EFA, and two employed CFA. Regarding the next point, only three of the articles reported the factor extraction method used, including Kaiser’s eigenvalue, criterion, scree plot test, parallel analysis and Velicer’s MAP test. Instrument validations yielded a total of two factors in five of the seven articles, while one yielded a single dimension [ 25 ] and the other yielded three dimensions [ 29 ], as in the original instrument. The interfactor R was reported only in the study by Zhong and Lou [ 29 ], whereas in the study by Martínez et al. [ 25 ], it could be easily obtained since it consisted of only one dimension. Internal replication was also calculated in the Spanish validation by randomly splitting the sample into two to test the correlations between factors. The effectiveness of the method was not reported in any of the articles. This information is presented in Table  3 in addition to a summary of the factor loadings.

The second section examined reliability. All the studies presented measures of internal consistency conducted in their entirety with Cronbach’s α coefficient for both the total scale and the subscales. The ω coefficient of McDonald was not used in any case. Four of the seven articles performed a test-retest test. Martínez et al. [ 25 ] conducted a test-retest after a period of seven days, while Le et al. [ 40 ] and Rokstad et al. [ 27 ] performed it between one and two weeks later and Sjögren et al. [ 28 ] allowed approximately two weeks to pass after the initial test.

The third section analyzes the calculation of invariance, which was not reported in any of the studies.

Evidence based on relationships with other variables

In the fourth standard, based on validity according to the relationship with other variables, the articles that reported it used only convergent validity (i.e., it was hypothesized that the variables related to the construct measured by the test—in this case, person-centeredness—were positively or negatively related to another construct). Discriminant validity hypothesizes that the variables related to the PCC construct are not correlated in any way with any other variable studied. No article (0%) measured discriminant evidence, while four (57%) measured convergent evidence [ 25 , 29 , 30 , 46 ]. Convergent validity was obtained through comparisons with instruments such as the Person-Centered Climate Questionnaire–Staff Version (PCQ-S), the Staff-Based Measures of Individualized Care for Institutionalized Persons with Dementia (IC), the Caregiver Psychological Elder Abuse Behavior Scale (CPEAB), the Organizational Climate (CLIOR) and the Maslach Burnout Inventory (MBI). In the case of Selan et al. [ 46 ], convergent validity was assessed on two items considered by the authors as “crude measures of person-centered care (i.e., external constructs) giving an indication of the instruments’ ability to measure PCC” (p. 4). Concurrent validity, which measures the degree to which the results of one test are or are not similar to those of another test conducted at more or less the same time with the same participants, and predictive validity, which allows predictions to be established regarding behavior based on comparison between the values of the instrument and the criterion, were not reported in any of the studies.

Evidence based on the consequences of testing

The fifth and final standard was related to the consequences of the test. It analyzed the consequences, both intended and unintended, of applying the test to a given sample. None of the articles presented explicit or implicit evidence of this.

The last two sources of validity can be seen in Table  4 .

Table  5 shows the results of the set of validity tests for each study according to the described standards.

The main purpose of this article is to analyze the evidence of validity in different validation studies of the P-CAT. To gather all existing validations, a systematic review of all literature citing this instrument was conducted.

The publication of validation studies of the P-CAT has been constant over the years. Since the publication of the original instrument in 2010, seven validations have been published in other languages (taking into account the Italian version by Brugnolli et al. [ 31 ], which could not be included in this study) as well as a modification of one of these versions. The very unequal distribution of validations between languages and countries is striking. A recent systematic review [ 51 ] revealed that in Europe, the countries where the PCC approach is most widely used are the United Kingdom, Sweden, the Netherlands, Northern Ireland, and Norway. It has also been shown that the neighboring countries seem to exert an influence on each other due to proximity [ 52 ] such that they tend to organize healthcare in a similar way, as is the case for Scandinavian countries. This favors the expansion of PCC and explains the numerous validations we found in this geographical area.

Although this approach is conceived as an essential element of healthcare for most governments [ 53 ], PCC varies according to the different definitions and interpretations attributed to it, which can cause confusion in its application (e.g., between Norway and the United Kingdom [ 54 ]). Moreover, facilitators of or barriers to implementation depend on the context and level of development of each country, and financial support remains one of the main factors in this regard [ 53 ]. This fact explains why PCC is not globally widespread among all territories. In countries where access to healthcare for all remains out of reach for economic reasons, the application of this approach takes a back seat, as does the validation of its assessment tools. In contrast, in a large part of Europe or in countries such as China or South Korea that have experienced decades of rapid economic development, patients are willing to be involved in their medical treatment and enjoy more satisfying and efficient medical experiences and environments [ 55 ], which facilitates the expansion of validations of instruments such as the P-CAT.

Regarding validity testing, the guidelines proposed by the “Standards” [ 37 ] were followed. According to the analysis of the different validations of the P-CAT instrument, none of the studies used a structured validity theory-based procedural framework for conducting validation. The most frequently reported validity tests were on the content of the test and two of the sections into which the internal structure was divided (i.e., dimensionality and internal consistency).

In the present article, the most cited source of validity in the studies was the content of the test because most of the articles were validations of the P-CAT in other languages, and the authors reported that the translation procedure was conducted by experts in all cases. In addition, several of the studies employed International Test Commission guidelines, such as those by Beaton et al. [ 47 ], Guillemin [ 48 ], Hambleton et al. [ 49 ], and Muñiz et al. [ 50 ]. Several studies also assessed the relevance, clarity and importance of the content.

The third source of validity, internal structure, was the next most often reported, although it appeared unevenly among the three sections into which this evidence was divided. Dimensionality and internal consistency were reported in all studies, followed by test-retest consistency. In relation to the first section, factor analysis, a total of five EFAs and four CFAs were presented in the validations. Traditionally, EFA has been used in research to assess dimensionality and identify key psychological constructs, although this approach involves a number of inconveniences, such as difficulty testing measurement invariance and incorporating latent factors into subsequent analyses [ 56 ] or the major problem of factor loading matrix rotation [ 57 ]. Studies eventually began to employ CFA, a technique that overcame some of these obstacles [ 56 ] but had other drawbacks; for example, the strict requirement of zero cross-loadings often does not fit the data well, and misspecification of zero loadings tends to produce distorted factors [ 57 ]. Recently, exploratory structural equation modeling (ESEM) has been proposed. This technique is widely recommended both conceptually and empirically to assess the internal structure of psychological tools [ 58 ] since it overcomes the limitations of EFA and CFA in estimating their parameters [ 56 , 57 ].

The next section, reliability, reports the total number of items according to Cronbach’s α reliability coefficient. Reliability is defined as a combination of systematic and random influences that determine the observed scores on a psychological test. Reporting the reliability measure ensures that item-based scores are consistent, that the tool’s responses are replicable and that they are not modified solely by random noise [ 59 , 60 ]. Currently, the most commonly employed reliability coefficient in studies with a multi-item measurement scale (MIMS) is Cronbach’s α [ 60 , 61 ].

Cronbach’s α [ 62 ] is based on numerous strict assumptions (e.g., the test must be unidimensional, factor loadings must be equal for all items and item errors should not covary) to estimate internal consistency. These assumptions are difficult to meet, and their violation may produce small reliability estimates [ 60 ]. One of the alternative measures to α that is increasingly recommended by the scientific literature is McDonald’s ω [ 63 ], a composite reliability measure. This coefficient is recommended for congeneric scales in which tau equivalence is not assumed. It has several advantages. For example, estimates of ω are usually robust when the estimated model contains more factors than the true model, even with small samples, or when skewness in univariate item distributions produces lower biases than those found when using α [ 59 ].

The test-retest method was the next most commonly reported internal structure section in these studies. This type of reliability considers the consistency of the scores of a test between two measurements separated by a period [ 64 ]. It is striking that test-retest consistency does not have a prevalence similar to that of internal consistency since, unlike internal consistency, test-retest consistency can be assessed for practically all types of patient-reported outcomes. It is even considered by some measurement experts to report reliability with greater relevance than internal consistency since it plays a fundamental role in the calculation of parameters for health measures [ 64 ]. However, the literature provides little guidance regarding the assessment of this type of reliability.

The internal structure section that was least frequently reported in the studies in this review was invariance. A lack of invariance refers to a difference between scores on a test that is not explained by group differences in the structure it is intended to measure [ 65 ]. The invariance of the measure should be emphasized as a prerequisite in comparisons between groups since “if scale invariance is not examined, item bias may not be fully recognized and this may lead to a distorted interpretation of the bias in a particular psychological measure” [ 65 ].

Evidence related to other variables was the next most reported source of validity in the studies included in this review. Specifically, the four studies that reported this evidence did so according to convergent validity and cited several instruments. None of the studies included evidence of discriminant validity, although this may be because there are currently several obstacles related to the measurement of this type of validity [ 66 ]. On the one hand, different definitions are used in the applied literature, which makes its evaluation difficult; on the other hand, the literature on discriminant validity focuses on techniques that require the use of multiple measurement methods, which often seem to have been introduced without sufficient evidence or are applied randomly.

Validity related to response processes was not reported by any of the studies. There are several methods to analyze this validity. These methods can be divided into two groups: “those that directly access the psychological processes or cognitive operations (think aloud, focus group, and interviews), compared to those which provide indirect indicators which in turn require additional inference (eye tracking and response times)” [ 38 ]. However, this validity evidence has traditionally been reported less frequently than others in most studies, perhaps because there are fewer clear and accepted practices on how to design or report these studies [ 67 ].

Finally, the consequences of testing were not reported in any of the studies. There is debate regarding this source of validity, with two main opposing streams of thought. On the one hand [ 68 , 69 ]) suggests that consequences that appear after the application of a test should not derive from any source of test invalidity and that “adverse consequences only undermine the validity of an assessment if they can be attributed to a problem of fit between the test and the construct” (p. 6). In contrast, Cronbach [ 69 , 70 ] notes that adverse social consequences that may result from the application of a test may call into question the validity of the test. However, the potential risks that may arise from the application of a test should be minimized in any case, especially in regard to health assessments. To this end, it is essential that this aspect be assessed by instrument developers and that the experiences of respondents be protected through the development of comprehensive and informed practices [ 39 ].

This work is not without limitations. First, not all published validation studies of the P-CAT, such as the Italian version by Brugnolli et al. [ 31 ], were available. These studies could have provided relevant information. Second, many sources of validity could not be analyzed because the studies provided scant or no data, such as response processes [ 25 , 27 , 28 , 29 , 30 , 40 , 46 ], relationships with other variables [ 27 , 28 , 40 ], consequences of testing [ 25 , 27 , 28 , 29 , 30 , 40 , 46 ], or invariance [ 25 , 27 , 28 , 29 , 30 , 40 , 46 ] in the case of internal structure and interfactor R [ 27 , 28 , 30 , 40 , 46 ], internal replication [ 27 , 28 , 29 , 30 , 40 , 46 ] or the effect of the method [ 25 , 27 , 28 , 29 , 30 , 40 , 46 ] in the case of dimensionality. In the future, it is hoped that authors will become aware of the importance of validity, as shown in this article and many others, and provide data on unreported sources so that comprehensive validity studies can be performed.

The present work also has several strengths. The search was extensive, and many studies were obtained using three different databases, including WoS, one of the most widely used and authoritative databases in the world. This database includes a large number and variety of articles and is not fully automated due to its human team [ 71 , 72 , 73 ]. In addition, to prevent publication bias, gray literature search engines such as Google Scholar were used to avoid the exclusion of unpublished research [ 44 ]. Finally, linguistic bias was prevented by not limiting the search to articles published in only one or two languages, thus avoiding the overrepresentation of studies in one language and underrepresentation in others [ 43 ].

Conclusions

Validity is understood as the degree to which tests and theory support the interpretations of instrument scores for their intended use [ 37 ]. From this perspective, the various validations of the P-CAT are not presented in a structured, valid, theory-based procedural framework like the “Standards” are. After integration and analysis of the results, it was observed that these validation reports offer a high number of sources of validity related to test content, internal structure in dimensionality and internal consistency, a moderate number of sources for internal structure in terms of test-retest reliability and the relationship with other variables, and a very low number of sources for response processes, internal structure in terms of invariance, and test consequences.

Validity plays a fundamental role in ensuring a sound scientific basis for test interpretations because it provides evidence of the extent to which the data provided by the test are valid for the intended purpose. This can affect clinical practice as people’s health may depend on it. In this sense, the “Standards” are considered a suitable and valid theory-based procedural framework for studying this modern conception of questionnaire validity, which should be taken into account in future research in this area.

Although the P-CAT is one of the most widely used instruments for assessing PCC, as shown in this study, PCC has rarely been studied. The developers of measurement tests applied to the health care setting, on which the health and quality of life of many people may depend, should use this validity framework to reflect the clear purpose of the measurement. This approach is important because the equity of decision making by healthcare professionals in daily clinical practice may depend on the source of validity. Through a more extensive study of validity that includes the interpretation of scores in terms of their intended use, the applicability of the P-CAT, an instrument that was initially developed for long-term care homes for elderly people, could be expanded to other care settings. However, the findings of this study show that validation studies continue to focus on traditionally studied types of validity and overlook the interpretation of scores in terms of their intended use.

Data availability

All data relevant to the study were included in the article or uploaded as additional files. Additional template data extraction forms are available from the corresponding author upon reasonable request.

Abbreviations

American Educational Research Association

American Psychological Association

Confirmatory factor analysis

Organizational Climate

Caregiver Psychological Elder Abuse Behavior Scale

Exploratory factor analysis

Exploratory structural equation modeling

Staff-based Measures of Individualized Care for Institutionalized Persons with Dementia

Maslach Burnout Inventory

Multi-item measurement scale

Maximum likelihood

National Council on Measurement in Education

Person-Centered Care Assessment Tool

• Person-centered care

Person-Centered Climate Questionnaire–Staff Version

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

International Register of Systematic Review Protocols

Standards for Educational and Psychological Testing

weighted least square mean and variance adjusted

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This work is one of the results of research project HIM/2015/017/SSA.1207, “Effects of mindfulness training on psychological distress and quality of life of the family caregiver”. Main researcher: Filiberto Toledano-Toledano Ph.D. The present research was funded by federal funds for health research and was approved by the Commissions of Research, Ethics and Biosafety (Comisiones de Investigación, Ética y Bioseguridad), Hospital Infantil de México Federico Gómez, National Institute of Health. The source of federal funds did not control the study design, data collection, analysis, or interpretation, or decisions regarding publication.

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L.M.B.L. conceptualized the study, collected the data, performed the formal anal- ysis, wrote the original draft, and reviewed and edited the subsequent drafts. M.M.V. collected the data and reviewed and edited the subsequent drafts. C.M.S. collected the data, performed the formal analysis, wrote the original draft, and reviewed and edited the subsequent drafts. J.L.S. collected the data, wrote the original draft, and reviewed and edited the subsequent drafts. J.G.E. collected the data and reviewed and edited the subsequent drafts. F.T.T. conceptualized the study and reviewed and edited the subsequent drafts. L.M.B.L. conceptualized the study and reviewed and edited the subsequent drafts. M.M.V. conceptualized the study and reviewed and edited the subsequent drafts. C.M.S. reviewed and edited the subsequent drafts. J.G.E. reviewed and edited the subsequent drafts. F.T.T. conceptualized the study; provided resources, software, and supervision; wrote the original draft; and reviewed and edited the subsequent drafts.

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Bru-Luna, L.M., Martí-Vilar, M., Merino-Soto, C. et al. Person-centered care assessment tool with a focus on quality healthcare: a systematic review of psychometric properties. BMC Psychol 12 , 217 (2024). https://doi.org/10.1186/s40359-024-01716-7

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• 2 Municipality of Copenhagen, Denmark

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Background: There has been an increasing interest in the concept of hope within the field of brain injury rehabilitation. Existing reviews have nevertheless focused on stroke, leaving out the broad populationgroup of people with acquired brain injury (ABI). Furthermore a just as majority of the included studies in those reviews excluded the subgroup of people with communication difficulties, thus primarily giving voice to a select group of people with ABI. Methods: A qualitative systematic review was conducted with the purpose of systematically reviewing and thematically synthesise findings about hope as experienced by adultspeople with ABI in a rehabilitation or recovery process. The search strategy included peer-reviewed qualitative studies published after 2000 in English or Scandinavian languages. Searches of EBSCO databases incorporating CINAHL, MEDLINE, and PsycINFO were conducted together with SocINDEX, Social Work Abstracts, Eric and Web of Science. Ten qualitative studies were included, and the Critical Appraisal Skills Program (CASP) was used for assessing the quality and relevance of the ten studies. Qualitative findings were synthesized using Thomas and Harden's methodology. data were analysed based on methods for thematic synthesis by Thomas and Harden. Results: Through a thematic synthesis eleven subthemes were identifiedemerged relating to experiences of hope. These were grouped into four analytical themes: (1) Hope a two folded phenomenon; (2) Time and temporality; (3) Progress, goals and visibility and (4) The alliance. Conclusion: This review has shown that even though hope has both a positive and negative side to it, it is necessary as a driving force for people with ABI in terms of supporting them to keep going and not give up. Rehabilitation professionals are advised to embrace the ambiguity of hope, customizing the support of hope to each person with ABI. Attention is needed on how to make progress visible for persons with ABI during their rehabilitation process just as rehabilitation professionals should acknowledge the alliance with the person with ABI as a core component of rehabilitation. This requires a focus on professionals' communication skills if hope promoting relationships between professionals and persons with ABI are to be achieved.

Keywords: hope, acquired brain injury, Rehabilitation, Recovery, literature review, qualitative studies, thematic synthesis

Received: 26 Jan 2024; Accepted: 26 Apr 2024.

Copyright: © 2024 Højgaard Nejst and Glintborg. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

* Correspondence: PhD. Camilla Højgaard Nejst, Aalborg University, Aalborg, Denmark

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