Volume 23
Number 2
2002

[Table of Contents]

Cross-Canada Forum

Use of focus group methodology in the development of an Ontario farmers' sun safety survey

Abstract

Farmers are at higher risk for skin cancer; US studies indicate that they do not use adequate sun protection. Little data on Canadian farmers' sun exposure are available, and a literature review suggests a strong need to develop a comprehensive, easy to complete farmers' sun safety survey in order to identify sun safety issues in the farming community. A literature review contributed to the development of a draft farmers' sun safety survey. Preliminary testing of the survey with 207 Ontario farmers supported the usefulness of the questionnaire, but weaknesses remained in phrasing and missed concepts. To augment the questionnaire's development, focus groups were held with farmers in four Ontario communities to clarify the phrasing of survey questions concerning the amount of sun exposure, the use of sun protection practices, family/personal history of skin cancer, and skin cancer attitudes and knowledge. This paper reports on what was learned substantively from these focus groups.

Key words: farmers, focus group method; skin cancer, survey design

Introduction

The "National Survey of Sun Exposure and Protective Behaviours" determined that nearly 20% of persons residing in Ontario aged 15+ during the summer of 1996 had a job that required them to work outdoors.¹ Over 60% of these reported spending more than two hours per day, on average, working outdoors. This study demonstrated that although outdoor workers were more likely to wear hats and clothes than other adults, they did not use other sun protection measures, such as sun avoidance, seeking of shade, use of sunscreen, or wearing of sunglasses.¹ However, this survey of 1,000 Ontario adults did not capture more detailed information about specific occupational groups, actual details of exposure (in terms of hours per day, time of day, etc. beyond the statistics quoted above) or details of protection (i.e., type of hat, type of clothing). Yet the results indicate that a sizeable segment of Ontario's outdoor workers is experiencing significant sun exposure during the summer months without taking adequate measures to minimize the effects of such exposure. One such group is Ontario's farmers.

Farmers are at higher risk for skin and lip cancer, both of which are associated with substantial exposure to sunlight.^2-4 There is some evidence that farmers are at increased risk of ocular melanoma,^5-7 although other studies have not reported this association.^8-10 Melanoma and non-melanoma skin cancers have been increasing in incidence in fair-skinned populations around the world, including Canada;¹¹ skin cancer is by far the most commonly occurring cancer in Canada.¹² Yet two US studies that examined farmers' sun safety practices indicated that a minority of farmers protect their skin.^2,13

Behavioural research, in particular research based on the Health Belief Model (HBM), has been used to explain why some individuals adhere to prevention practices while others do not. The HBM predicts that preventive action will be taken if people believe that they are susceptible to a disease, that the disease will seriously impact their lives, that the preventive action will reduce their chance of acquiring the disease, and that the preventive action is easy to follow.¹⁴ In addition, the individual's age, gender, educational level, knowledge of the disease, and prior contact with the disease have been implicated as further influences in the preventive decision-making process.¹³ Based on this model, the strongest predictors of health protective behaviours were "perceived barriers", which were demonstrated to be negatively associated with efforts to reduce sun exposure in Wisconsin dairy farmers, and "lack of knowledge of skin cancer" played only a minor role. When a group of Australian outdoor workers, however, was subjected to an educational intervention trial, an increase in sun-protection behaviours was seen.¹⁵ This result suggests that knowledge may play a more important role in prevention practices than has been previously demonstrated.

A pilot survey of sun exposure and behaviour in Ontario farmers was undertaken in October 1998. The draft survey was completed by 207 farmers attending a plowing match in Frontenac County in southeastern Ontario. A member of the study team administered the survey. Data from the survey demonstrated that nearly 30% spent eight hours or more in the sun each day, on average, between April and October. Nearly 35% of the 207 participants reported wearing a wide-brimmed hat always or most of the time, and only 22% wore long-sleeved shirts always/most of the time. Most of the respondents (85%) routinely wore long pants. Few farmers (25%) used sunscreen on a regular basis and only about 44% reported wearing sunglasses "always/most of the time". These pilot results suggest that Ontario farmers do indeed have high exposure and are likely not using adequate sun protection. This survey revealed some barriers (i.e., sunscreen is "too sticky"), but this information was obtained only anecdotally, during follow-up interviews with approximately 30 of the original survey participants. Results on the use of protection are similar to those reported by researchers in the United States in that approximately 37% of men reported wearing wide-brimmed hats and long-sleeved shirts.^2,13 Almost all of the 207 participants voiced concern over the wording of the preliminary survey, prompting a further need to investigate whether the questions asked were clear and relevant to the farming community.

In 1996, there were 851,400 Canadian farmers, almost 100,000 of whom reside in Ontario.¹⁶ Apart from the results of the small pilot study noted above, information is lacking concerning how much sun exposure they receive, and how this varies by type of farming. While there are effective ways to reduce sun exposure, the level of knowledge about these and the actual protective practices of Ontario farmers are not known. Barriers, perceived or real, to effective sun protection among farmers are likewise not known.

This report describes the results of focus groups with Ontario farmers, the purposes of which were to develop a survey to measure the knowledge, attitudes and behaviours of farmers with regard to sun-safety practices, and to ascertain the most appropriate strategy to implement the survey.

Methods

Surveys are commonly developed to measure the extent of a population's knowledge, attitudes, intentions to act, and behaviours. There are several different methods used by researchers to develop survey instruments. Typically, investigators develop a draft questionnaire through a team brainstorming process, by compiling questions from other, previously developed survey instruments, and/or through input from colleagues and representatives of the survey target population. This step is generally followed by a review by other experts to identify ambiguities in wording, item selection, and response option. Next, the questionnaire is revised based on the responses of a pre-test subsample of the intended survey population. The pre-test also aids in testing the psychometric properties of the instrument and the feasibility of the survey distribution method. Finally, the revised survey instrument is disseminated to the target audience. In addition, it is now becoming increasingly common to conduct focus group interviews, either before developing or prior to implementing a structured questionnaire.^17-19 This process can help identify issues to be included in the questionnaire, formulate question categories, simply fine-tune wording on particular questions, and/or ascertain the most effective strategies to reach the target population with the survey instrument.

Development of initial draft questionnaire

A draft of the farmers' sun safety survey instrument was developed after a thorough review of the English language published literature. MEDLINE was searched using a combination of key words for sun exposure, farmers, questionnaires, and surveys. Reference lists of key studies were prepared and three experts (dermatologists and/or epidemiologists) were consulted for content. The initial draft questionnaire was then prepared, incorporating as many of the questions as possible identified by the literature search and expert input.

The initial draft instrument contained the following components: demographic information, sun protection practices, personal/family history of skin cancer, skin examination practices, and skin cancer knowledge, attitudes and beliefs. The "sun protection practices" section included questions on the amount of sun exposure and the frequency of use of clothing, sunscreen, work gloves, and sunglasses as sun protection aids. Twenty-two questions were included in the original questionnaire. The majority of the questions were closed-ended, offering the participant specific response options (with a residual or "other" category); others used a Likert-type scale. After consulting the Ontario Sun Safety Working Group (OSSWG) and three survey design experts, the second draft questionnaire was expanded to 36 questions, but the skin examination practices section was shortened.

The second draft questionnaire was pre-tested with 10 farmers who were patients at either the Women's College Hospital or the Toronto Sunnybrook Regional Cancer Center pigmented lesion clinics. Revisions of the questionnaire were made on the basis of any difficulties encountered during the pre-testing. A shortened version of the second draft questionnaire, focusing on demographics and sun protection practices, was administered at the 1998 International Plowing Match in Frontenac County, Ontario. The purpose of this comparatively brief survey was to obtain baseline data on the current sun protection practices of Ontario farmers and the reasons for any limited usage of such practices. Although additional sun exposure information would have been beneficial, the questionnaire was limited to two pages in length to optimize participation. Two hundred and seven Ontario farmers were surveyed at the time. Further revisions to the questionnaire, which consisted mostly of question rewording, were made based on the analysis of the data provided by farmers surveyed at the plowing match. The final draft questionnaire, which consisted of 36 questions (with additional sub-questions, the total number of items to which a respondent could reply was 66), was administered to the focus groups. Chart 1 (in appendix) illustrates the survey question sections, issues addressed in each section, and the number of items per section.

Focus groups

Four focus groups were planned, comprising farmers from four different farming communities across the southern part of Ontario. Two of the focus groups were affiliated with the Ontario Farm Safety Association Incorporated, while the other two were assembled through contacts with community-based organizations. The groups were conducted in English and tape-recorded (with participants' permission) to facilitate data capture and analysis. The University of Toronto approved the ethical conduct of this study.

An informational package was distributed to participating farmers' groups prior to the meeting. This package included a cover letter describing the project, the focus group questions to be asked of group participants to obtain feedback on the interpretability, clarity and completeness of the draft farmers' sun safety survey, a copy of the farmers' sun safety survey, and an informed consent form. Participants were informed that all responses would be analyzed as a group and combined with data obtained from the other focus groups. The consent form also explained that participation was voluntary and anyone could withdraw at any time during the session. Prior to the group discussion, each participant read and, if s/he agreed, signed the consent form. Each focus group participant received a small honorarium to help defray any transportation or other costs.

The focus group interviewing format included brainstorming opportunities combined with a limited set of predefined questions functioning as prompts to provoke discussion. Participants were asked to review the survey questions prior to the session, and ongoing references were made to survey sections and questions.

One trained facilitator and an assistant were present during each of the focus group sessions. The facilitator led the focus group discussion, while the assistant took notes. Participants were asked to comment on the completeness, understandability, ease of answering, and acceptability of the survey questions. During the first half-hour of the focus group session, the participants' general comments about the survey were solicited. The remaining time was devoted to assessing the survey instrument item-by-item, including its wording, content, interpretation, and comfort levels. Suggestions for additions or deletions to the survey were encouraged. The session concluded with a discussion on ways of delivering the survey to farmers to optimize the response rate.

The focus groups were conducted sequentially to build an inductive understanding of the participants' responses to the survey, so that responses from earlier groups were shared with subsequent groups. This was done to validate and elaborate the focus group data. As recommended by Kreuger,²⁰ the final group was used to clarify, elaborate, and confirm our understandings of the first three focus group discussions.

Results of focus group interviews

Four focus group sessions, involving 34 farmers (28 men, six women) were conducted between the months of March and June 1999. All of the participants were white part-time or full-time farmers, and over the age of 30. The number of participants in each group ranged from five to 10, with each session lasting approximately two hours.

The majority of focus group participants believed that sun safety was an important, but not well recognized, health issue among farmers. Many participants indicated that they had learned more about sun protection and skin cancer during the focus group discussions than from any other educational sources in the past. Almost all of the participants felt that the questionnaire was of an acceptable length, requiring only 20 minutes to complete, and was sufficiently comprehensive to capture farmers' sun safety issues. Most participants felt that the questions were easy to answer. They found the closed-ended format acceptable, recognizing it as a timesaving approach (as opposed to trying to provide hand-written responses to open-ended questions). There were some recommendations, however, to modify response options to some of the questions to avoid "insulting" or "confusing" persons completing the survey. Below, we clarify the focus group participants' recommendations for changing the survey questions.

Background information

In the "Background Information" section of the survey, participants were asked basic descriptive questions about themselves and their farming. One of the questions asks about the highest level of education the survey respondent has achieved. Initially, all focus group members objected to this question. They suggested the data to be derived from a question about education was "irrelevant" and "insulting". However, after we explained that it is one of our intentions with the survey to see if there is a correlation between education level and sun protection usage, the focus group participants accepted the need to have a question about education. We incorporated their recommendation to modify the education question to include an additional response option of graduating from university/college, as the participants suggested we could offend farmers who are asked to complete the questionnaire who have post-secondary education, in addition to an explanation as to why the question was asked.

A few of the participants suggested that the answer options pertaining to type of farming be shortened. For example, the participants recommended that we collapse "dairy farming" and "livestock farming" into one response because these activities are essentially the same for most farmers.

Many farmers felt that the question about financial security was irrelevant and recommended that it should be dropped or a rationale provided for its inclusion in the survey. We refined the question on financial security by providing an explanation that financial resources may be a factor in sun-protection practices, and moved the question from section 1, "Background Information", into section 2, "Time in the Sun".

Time in the sun

In this section, many participants felt that clarification was needed as to whether being in a tractor cab, whether enclosed by ultraviolet-protected glass or not, was really considered to be "outdoors". We refined the survey to gather data on the amount of time that included "tractor work, regardless of whether you are in a cab or under a covering".

When questioned about sun protection use, a few of the focus group members felt that "T-shirts" and "Short-sleeve shirts" should be treated as two different sun protection practices, requiring separate questions. Moreover, some of the participants felt that there should be additional questions on whether they wore shirts at all when farming. In addition, the majority of focus group members felt that some of the answer options as to why certain sun protection practices were not done should be eliminated so as not to insult the respondents.

Other questions

In the section on "Personal/Family History", focus group participants recommended that we drop most of the questions asking them to reflect on their childhood. Everyone felt that they would remember a severe sunburn, but would not remember how much exposure to the sun they experienced before they were 12 years old.

Most participants felt that farmers do not know how to examine their skin to identify a suspicious lesion, and most suggested that their physicians may not be doing this routinely during a physical examination. Thus, with respect to questions on the farmers' sun safety survey pertaining to "Skin Examination Practices", the participants felt that additional questions were needed to determine the farmers' level of knowledge of the practice of basic skin examination and to assess their level of action if a suspicious lesion was found.

In the "Knowledge and Attitudes" section, we asked group participants their opinion of the question in the draft survey that asked survey participants to rank a list of 10 health concerns according to importance (where 1 was the most important health concern and a 10 was the least important health concern). Several focus group participants had difficulty ranking the list of 10 health concerns because some of the terms used to describe the health issues were unknown to them. Instead, they recommended that survey participants should be asked to identify, from a list of 10 options, the three most serious health concerns for farmers.

Information about skin cancer and sun safety may be available from a variety of sources, including health care providers, public health personnel, the Canadian Cancer Society and other community-based organizations, the Canadian Association of Dermatologists, and the federal and provincial governments. We felt it was important to include questions on the survey about how farmers acquire knowledge about skin cancer and sun safety. Focus group participants felt that friends and family were important answer options and recommended we included these options in the survey. Finally, some participants recommended that presentations be made at plowing matches and conferences/workshops of the Ontario Farm Safety Association Incorporated (including local chapters). Materials on sun safety, such as pamphlets, videos and other media, could also be provided at these events.

Chart 2 illustrates the survey sections and question issues for the revised version of the survey, as well as the number of question items, based on the findings from the focus groups. The revisions resulted in a total of 64 items to which responses could be obtained.

Survey dissemination

All in all, participants felt that the questions were relevant, and that the health-related issue of sun safety was of sufficient concern to individual farmers as to merit the design and implementation of the survey. As further indication of the acceptability of the survey, many participants, who were senior members of the Ontario Farm Safety Association Incorporated for their locale, expressed willingness to assist in any further steps to ensure the successful dissemination of the survey. Enthusiasm for the project generally, and sun safety in particular, was further demonstrated when many of the members requested that more pamphlets and written information be made available to them at their local farm safety association offices.

Many participants felt that the survey could be disseminated through channels facilitated by the Ontario Farm Safety Association Incorporated and the Ontario Farmers' Association. They felt that the cover letter, as currently designed and signed by the scientists, would be effective, but some thought that having a senior member of the Ontario Farm Safety Association Incorporated sign the cover letter as well may increase the response rate. Several participants suggested that current surveys they receive from agriculture chemical manufacturers attach a small financial incentive (a "toonie") to recognize the time taken by the farmer to complete and return the survey. Others, however, felt that completing the survey was "educational" and that, in itself, was a reward. It was also recommended that the return envelope should be self-addressed and pre-stamped. Furthermore, to increase the response rate, some of the participants suggested prize draws, sunscreen coupon enclosures, and prizes from various seed companies.

Discussion

The focus groups of Ontario farmers provided useful information on the design, content, wording, and implementation of a farmers' sun safety survey. Recruitment of participants to the focus groups was successful, supported extensively by working directly with farmers' associations and community-based groups, and conducting the groups in convenient, community-based settings optimized participation. According to focus group participant feedback, providing information packages that included a copy of the survey to be discussed prior to the focus groups facilitated the participant's preparation for, and stimulated interest in, the groups.

It is possible that some selection bias occurred during recruitment (a significant number of the participants were formally affiliated with the Ontario Farm Safety Association Incorporated). However, since the purposes of the focus groups were to identify weaknesses in the wording of the questionnaire and to identify mechanisms to optimize the response rate, a sampling methodology that relied on key organizations to which farmers are affiliated was appropriate. The fact that the participants may have been uniquely well informed about occupational health and safety issues, including sun safety, should be construed as a positive contribution to the development of a survey to identify, in a comprehensive manner, the most important issues concerning farmers' sun exposure and sun-protective behaviours. Furthermore, the Ontario Farm Safety Association Incorporated may be an effective mechanism to facilitate the dissemination of the sun safety survey.

Participants agreed that sun exposure and sun safety were of sufficient concern to farmers to warrant the design and implementation of the farmers' sun safety survey. The focus groups yielded important and useful feedback to modify the survey in ways that will make questions clearer and easier to complete.

It is apparent from this instrument development study that current knowledge about sun safety is lacking in the farming community (as may be the case with other groups and individuals). Our next step is to test the psychometric properties of the survey, including reliability, validity, and responsiveness, in order to have an instrument that can be used to assess the needs of the farming community. Because the focus groups were conducted in Ontario, it will also be necessary to test the instrument with farmers residing in other jurisdictions to determine if the questions and wording are acceptable, clear and complete.

Conclusions

Given the large number of farmers in Ontario, the substantial sun exposure they experience, presumably over many years, the apparent lack of sun protection employed, the relatively high frequency of harmful effects of overexposure to the sun such as skin cancers and cataracts, with their attendant costs to the individual and to the health care system, and the lack of regulations covering farmers' sun exposure and use of protective measures in their workplaces, it is important to develop strategies for voluntary reduction of their sun exposure. This cannot be done until we know more about their current exposure, protection, perceived barriers and knowledge and their determinants. The knowledge derived from the farmers' sun safety survey will, we anticipate, yield data to allow for the design and implementation of sun-safety strategies (i.e., interventions targeting certain types of farmers, age groups, etc.).

Acknowledgements

The authors wish to thank the Ontario Farm Safety Association Incorporated, the Ontario Farmers Association, the Junior Farmers Association, the Ontario Plowman's Association, the Ontario Sun Safety Working Group, Dairy Farmers of Ontario, Farm and Country magazine, and the following companies: Beaver Lumber, Cosmair Groups L'Oreal, Gay Lea Foods Co-operative Limited, Kettleby Herb Farms Limited, Mountain Equipment Co-op, Nuts to You Nut Butter Company, Stiefel Company Limited, and Westwood-Squibb for their support and donations during the early phases of the instrument's development. In addition, we would like to thank the following individuals for their time and effort: Ms. Tanya Cecic, Ms. Irene Gilmore, Dr. William Ho, Dr. Ian Johnson, Mr. Mark Purdue, Ms. Alison Conley, and Ms. Jane Reed. This survey was developed in part through a contract provided by Health Canada (Contract #8-SC2041). Health Canada does not assume any responsibility for the results and conclusions described herein. The study team especially wishes to thank the women and men who participated in the study and generously offered their time to facilitate the development of the instrument.

References

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16. Statistics Canada. "Operators, classified by number of operators on the farm, selected variables, 1996, Ontario". Retrieved from website <http://www.Statcan.ca/english/censusag/dec15/ont1.htm>.

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20. Kreuger RA. Focus Groups: A Practical Guide for Applied Research. Newbury Park, California: Sage Publications, 1988.

Appendix

CHART 1
Farmers' sun safety survey questions:
original survey sections and key issues covered

CHART 2
Farmers' sun safety survey questions:
revised survey sections and key issues covered

Author References

Fredrick D Ashbury, Department of Oncology, McGill University and Faculty of Nursing, University of Manitoba and Optx Corporation, Denver CO, USA

Dr Sabrina Yun Ing, University of Western Ontario

Loraine D Marrett, Division of Preventive Oncology, Cancer Care Ontario and Associate Professor, Dept of Public Health Sciences, University of Toronto

Dr Lynn From, Division of Dermatology, Women's College Campus, Sunnybrook Women's College Health Sciences Centre and University of Toronto

Kristina V Perry

Correspondence: Fredrick D Ashbury, 25 Balsdon Crescent, Whitby, Ontario L1P 1L5; Fax: (905) 668-5205; E-mail: fredash@optxcorp.com

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