AS A DATA GATHERING TOOL : ITS APPLICATION TO NURSES ' UNDERSTANDING OF HIV INFECTION AND AIDS

The focus group interview (FCI) is a research method not commonly used by nurses. It is an effective method if qualitative data are needed and may be used independently to get indepth information, but also can be used in conjunction with tools such as questionnaires, to elicit information that could not be gathered otherwise. For the FGI to be applied correctly the researcher must be well versed with its contents, and ensure that the primary reason for using such a method is solely to collect data. Other reasons like decision-making or reaching a consensus would not be appropriate. The researcher has shown how this method was used in a study in a specialised hospital in Durban which examined professional nurses' knowledge and understanding o f AIDS and HIV infection. The results not only illustrated knowledge and understanding, but raised sensitive issues and dilemmas related to caring for HIV infected patients. Areas o f further research were highlighted and recommen­ dations made.


INTRODUCTION
Focus group interview (FGI) is a type of indepth interview whereby a limited number of interacting individuals with common interests and characteristics relevant to a particular study or topic is used to elicit information that could not be obtained when using other methods of data collection.Shortly, FGI is a carefully planned discussion, designed to obtain perceptions, on a defined are a o f in te r e s t in a p e rm is s iv e , n o n -th re a te n in g e n v iro n m e n t.T he participants are selected because they have certain characteristics in common that relate to the topic of the focus group.The group members influence each other by responding to ideas and comments in the discussion.Such discussion is not a free-wheeling conversation among group members, but has focus and a clearly identifiable agenda.(Krueger 1988:18 ;Stewart 1990: 10-18;Polit & Hungler 1991: 279-280) In the following discussion, the FGI is applied in a study carried out in 1993 in order to exansine professional nurses' knowledge and understanding o f AIDS and HIV infection.

REVIEW O F LITERATU RE P U R PO S E O F T H E FO C U S G R O U P IN T E R V IE W Exploratory
It is advisable where little is known about the topic/ problem.FGI directly taps into human tendencies like attitudes and perceptions, thus eliciting infonnation that may not be available when using other methods of data collection.
It can be used during the same time as a q u a n tita tiv e p ro c e d u re w hen in d ep th information is needed (triangulation).This would yield both depth and breadth of information and enhance the validity of the study (Morgan 1993:24) Pilot FGI can be used as a starting point for the design of survey questionnaires because it helps provide a means for exploring the ways potential participants talk atout objects and events.This material will help in identifying alternatives for closed-ended survey items and enable the researcher to identify clues about special problems that may develop in the quantitative data collection phase.

Confirm atory
This kind of interview breaks the tendency to make assumptions about human behaviour, things and reality in general and may be done during the course of a programme to test effectiveness and perceptions of such a programme.On recruitment of new cUentele into the existing programme, one can use such a method to get perceptions and feelings about the programme at hand.(Krueger 1988:34 ;Morgan 1993:23)

Evaluation
When the core aim is to evaluate a programme, one uses the FGI at the end of the programme (summative evaluation) or following certain incidents and procedures.These include :-• patient care : to determ ine how the recipients view the kind of care given.
• new product : post use, to evaluate how subjects felt about the new product.
• e x it in te rv ie w : to u n d e rsta n d th e organisational image.
• as a follow-up to a postal survey.(Krueger 1988:36 & Stew artl990:15) FG I as an independent method This is helpful when insights, perceptions and ex p lan a tio n s are m ore im p o rtan t than numerical information.(Krueger 1988:31-40 ;Morgan 1993:1-4 & Stewart 1990: 10-18) How to use the FGI   The guide helps to make sure that the desired direction is followed during the interview, and that all aspects are covered.T here could be a list o f issues for discussion, and could contain one or two open-ended questions.(Stewart 1990: 51-55) e) S am pling an d R e cru itm en t of P artic ip an ts The participants should know the purpose of the study.Stewart (1990) recommends the use of incentives as a compensation for time spent in the focus group which may include giving up of lunch time.(Stewart 1990:55) f) C onducting the Interview This will be further explained in the application used.
g) A nalysis a n d In te rp re ta tio n of D ata Since th is is a q u alitativ e m ethod, numerical data are not necessary.Data are interpreted by a content analysis and categorising themes, ideas and opinions expressed by the various groups.
T H E STUDY: The purpose of this study was to determine p ro fe s s io n a l n u rs e s ' k n o w le d g e and understanding of AIDS and HIV infection.To this end, research was carried out in a specialised Durban hospital during 1993.The FGI was used prior to the questionnaire method, to ensure triangulation and to elicit information that could not be gathered by other methods.The goup participants were registered nurses who were not going to be included in the questionnaire data-collecting m ethod and were chosen by purposive sam pling.T his help ed in avoid study contamination.Initially the focus group was to be formed by 24 participants but at the end only 21 turned up.Participants were chosen randomly for the 3 interview groups.

Realisation of the Study
Three groups were interviewed.Two groups were fonned by 8 participants, and the third group was formed by 5 nurses as it coincided with the pay day and respondents were rushing to go to town during their lunch hour.The interview was carried out in a central place accessible to all p articip an ts, and was perceived by them to be non-threatening.
Prior to the interview, verbal consent was obtained from all participants.The purpose of the snidy was explained, and the reason for the FGI was explained.The tape recorder, recommended by Stewart (19W), was not used.This was due to the political situation and general instability throughout the whole community since it was the transitional period prior to the new government.Instead, with participants' permission, key points/words used during the discussion were documented in writing.Total confidentiality was assured as results would under no circumstances state the participants name.

» Theoretical F ram ew ork
Two theories were com bined to form a conceptual framework.These were:-

Knowledge
The discussion focused on professional nurses knowledge and perceptions of AIDS and HIV infection.Due to the fact that the interviews were in group form, the results were not put in numerical form but words like majority, some and few were used.
The majority of the nurses could differentiate between AIDS and HIV infection, although some could not state the different stages.The nurses identified a need for intense education on AIDS/HIV infection, to be given on an on-going basis so as to keep them up to date.

Fears
Almost all participants expressed fear of contracting the disease.The expressed fear was three-fold -more than half had fear of catching the disease at the workplace.
-all had fear of contracting the infection from the sexual partner, since general a p p e a ra n c e c o u ld n o t te ll o f a perso n 's seropositivity, especially during the early stages.
-all expressed fear of undergoing the test which makes one "know" o f one's sero-positivity.
All three groups believed that people do not die because of advancement of the disease but because of "knowing" and the depression associated with the disease.

Dissonance
The discussion revealed uncertainty and discomfort as far as the universal precautions a g a in st in fe c tio n are co n c e rn e d .The participants excused themselves for lack of knowledge and gave the reason that they have not yet done the AIDS counselling course.But further to that they expressed confusion that was perpetuated by new discoveries that occur from time to time.The discomfort was further increased by the fact that the virus lives even on a dead body.On exploring the feeling about the use of plastic bags for the deceased, the majority felt uncoinfortable, since that was seen as interfering with socio-cultural customs of the family concerned.It was also felt that the practice meant disclosure of the diaposis.This is an area in need of further research.

Confidentiality
A ll p a r tic ip a n ts w ere w o rrie d and uncomfortable about the use of plastic bags as they felt that this raised suspicions from people since dead bodies are not usually wrapped in plastic.It was felt that this practice actually breaks the so called" confidentiality".
Search for C ure There were a number of participants who believed that there is a herbal cure for the disease and it was felt that the traditional healers should be encouraged to come forward with their herbal treatment.Participants felt that although the herbal treatment is said to be available , it is difficult for the traditional healers to come forward because they are not consulted and involved in healthcare.An aspect of exploitation was also raised whereby it was felt that the traditional healers have in the past discovered herbs that are used to cure ce rtain d ise a se s, and these have been translated to W estern m edicine with no recognition given to the traditional healer concerned.This is another area for further research.

Dilemnias
A number of issues were raised that could be classed as dilemmas for these professional nurses who saw no clear cut solutions to these.
The dilemma that could not be resolved was that of rape victims who test HIV positive.The nurses felt helpless as far as that was concerned.
The second dilemma was that of sero-positive patients who get discharged still bearing the "revenge" attitude and therefore continue to spread the disease since they "do not want to die alone".
The third dilemma was about those who hve on casual sex and the risks associated with such practices.
T he fo u rth dilem m a was about blood transfusion, everybody felt threatened about the "unreliable" screening done in the blood banks, further comphcated by the window period.

The Use o f Condoms
On exploring the beliefs and attitudes about condom use, it was discovered that condoms had not yet gained total acceptabihty, even amongst the nursing staff.There was a strong cry for female condoms (femidom) to be made available in South Africa.There seems to be a problem as far as the female condom is concerned, since apart from the expense and the unavailability of this condom, the partner needs to be informed about it.
All groups recommended breaking of confidentiality issues.It was felt that if HIV in fectio n could be like other infections, it would be easier to render the necessary care, and affected persons would have more courage to come forward for help.
2. Notification of the disease was another issue.The group felt that if the disease could be notifiable management would be easier although it is known that such a matter is difficult, particularly as a cure is not yet available.
3. Informing the community at large about condom use, since condoms appeared not to have gained acceptability even to nursing staff.
4. Setting up a campaign recruiting the tfaditional healers to divulge potential cures.
5. Trying of various teaching methods to ensure acknowledgement of the disease, since there are still people who deny its existence.
6. D elivering an intensive educational programme on AIDS and HIV infection to the community at large and evaluating the available teaching aids and strategies, to ensure their effectiveness.
7. The inclusion o f counselling in the curriculum for basic nurse training.

CONCLUDING STATEM ENT
The FGl can contribute to the knowledge base in the health sciences as illustrated by the above presentation of this method and its application.
R E F E R E N C E S m o g e n o u s th is w o u ld be determined by the purpose of the study.The participants are informed of their similarities prior starting the interview, so that they would not be anxious about being chosen.-u n fam iliar w ith each other since familiarity tends to inhibit disclosures.(Krueger 1988: 27-28) c) D ata C ollection P ro c ed u re This method should examine perceptions, feelings and the manner of thinking of participants.d) Q u alitativ e D ata Such data produce insight to attitudes, perceptions and opinions of participants.The results are promoted by the fact that the interview takes place in a natural e n v iro n m e n t an d th e p a rtic ip a n ts influence each other.(Knieger 1988: 29-31) STEPS a) P ro b lem S tatem ent This includes definition and fonnulation of research questions.It is at this stage that the researcher decides what kind of information is needed and from whom it should be collected.b) S am ple an d S am p lin g M ethod a) C ognitive D issonance T heory This theory assumes that people want to maintain consistency in their beliefs, attitudes, values and behaviour.If individuals confront examples of their own inconsistency in these areas, they will experience psychological discomfort and be m o tiv a te d to e lim in a te th e inconsistency.(Wicklund & Brehim, 1976).h) F e a r o f C o ntagion This is an affective stress-response to illness.Fear of contagion is an anxiety response to perceived threat of catching the disease.Three behaviours characterise this fear: -avoidance, taking extreme precautions, verbal expression of fear regarding the disease.(Meisenhelder & La Charite, 1989) Both theories were combined and used in e x p lo rin g th e n u rs e s ' k n o w led g e and understanding of the problem.The discussion was directed forward eliciting characteristics o f fe a r, a v o id a n c e , u n c e rta in ty , dissonance/discomfort, knowledge and actual perceptions of various aspects of the disease .