Focus Group about Cigarette Smoking during Pregnancy - s

ATTACHMENT 4

SCREENING INSTRUMENT

RTI International is working with the Centers for Disease Control and Prevention (CDC) to conduct focus groups examining women’s views on smoking and reproductive health. They are inviting groups of women in to discuss their views with them and with each other. If you qualify for this project and participate in our focus group, you will receive a $75 incentive for your participation. During the focus group, representatives of CDC may also be observing the focus groups on site and/or listening via telephone. However, no one from CDC will know your full name. All information that you provide today and all information that you provide during the discussions will remain private. Right now I am going to ask you some personal questions, including questions about your cigarette use and plans to become pregnant, to see if you are qualified for the project. Some of the questions may make you feel uncomfortable. Your decision to answer the questions is completely voluntary and you can choose to stop answering questions at any time. Are you ready to begin?

[Instructions to screener: Do not read words in ALL CAPITAL letters or instructions in Bold out loud to respondent.]

1. Are you comfortable having a discussion in English?

 NO→ STOP: INELIGIBLE.

 YES

Smoking Status

2. Have you smoked at least one hundred cigarettes in your entire life?

 NO→ STOP: INELIGIBLE.

 YES

3. Do you now smoke every day, some days, or not at all?

 Every day

 Some days

 Not at all

Pregnancy History

4. Are you currently pregnant?

 NO

 YES→ STOP: INELIGIBLE.

5. Do you want to have a baby in the future?

 YES

 NO→ GO TO 7

 Don’t know→ GO TO 7

6. When do you want to have your next baby?

 Within the next 12 months

 more than 12 months from now

7. When was your last pregnancy? What was the month and year?

 Never been pregnant → GO TO 9

 Within the PAST 2 years

 More than two year ago→ STOP: INELIGIBLE.

Cessation History

8. Did you quit smoking during your pregnancy? [Quit: abstained from smoking for seven or more consecutive days.]

 NO

 YES

Socioeconomic Status Indicators

9. Do you have health insurance?

 NO→ GO TO 11

 YES

 REF→ GO TO 11

10. What type coverage do you have? Do you have private or public (Medicaid, Medicare, etc.) coverage CHECK ALL THAT APPLY.

 EMPLOYER

 SELF-INSURED

 PUBLIC (Medicaid, Medicare)

 REF

 DK

11. Are you or have you been enrolled in the WIC (Women, Infants, and Children) Program in the past 2 years?

 NO

 YES

 REF

12. What is the highest level of education you have completed?

 LESS THAN HIGH SCHOOL

 HIGH SCHOOL DIPLOMA OR GED

 TECHNICAL COLLEGE

 COLLEGE DEGREE (UNDERGRADUATE, ADVANCED)

 REF

13. What is your annual household income before taxes?

 Less than $15,080

 $15,081 - $20,080

 $20,081 - $31,200

 $31,201 - $41,600

 $41,601 and above

 Unemployed

 REF

 DK

Qualification Key

Question Number	Group 1	Group 2	Group 3	Group 4
1	Yes	Yes	Yes	Yes
2	Yes	Yes	Yes	Yes
3	Every day or some days	Every day or some days
4	No	No	No	No
5	Yes	Yes	No	No
6	Within the next 12 months	Within the next 12 months
7	Never been pregnant	Within the past 2 years	Within the past 2 years	Within the past 2 years
8			Yes	No
	Final Group Assignment:___________________________

WRAP-UP FOR EXCLUDED INDIVIDUALS:

Thank you for answering the questions today, but you are not eligible to participate in the focus groups examining women’s views on smoking and reproductive health. All information that you provided today will remain private. If you have any further questions about this project please call XXX-XXX-XXXX. Thank you again.

_______________________________________________________________________

WRAP-UP FOR INCLUDED INDIVIDUALS:

Thank you for answering the questions today; you are eligible to participate in the focus groups examining women’s views on smoking and reproductive health. All information that you provided today and all information that you provide during the discussions will remain private. You are scheduled to participate in the focus group on DATE at TIME at LOCATION. The focus group discussions will be audio-recorded to help RTI write their report to CDC. However, precautions will be taken to protect your information. Your identifiable information, the audio recording, and notes from the interview will be kept by the evaluation contractor, RTI, under lock and key. The findings from the focus groups will be reported in summary form so that the participants cannot be identified. RTI will retain a copy of the digital audio files on password protected computers and a share drive to which only RTI team members have access. The digital audio files will be destroyed within a year of the project’s end.

Project staff will offer participants the option of using only their first name or a pseudonym during the groups for their privacy. We ask that you please respect the privacy of the other participants in the focus group, and do not share what is said in the group after it is over.

We will send you a confirmation letter shortly providing you with information on the date, time and location of the study. Please call XXX-XXX-XXXX if you have any questions.