Prevention Communication Formative Research, #11 #12

Participant Screener (Background Information Sheet): October 2, 2008

OMB BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is #0990-0281. The time to complete this information collection is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

Focus Group Recruitment Screener

Interviewer: _______________ Date: _______________ Letter sent: _______________ Reconfirmation Call: _____________

PAG Formative Testing Focus Groups Birmingham, AL Group 1 _____ [Urban, Male, Age 21-40] Group 2 _____ [Urban, Female, Age 41-64] Group 3 _____ [Suburban, Male, Age 41-64] Group 4 _____ [Suburban, Female, Age 21-40] Group 5 _____ [Rural, Male, Age 41-64] Group 6 _____ [Rural, Female, Age 21-40] ------------------------------------------------------------------ Cleveland, OH Group 7 ____ [Urban, Male, Age 41-64] Group 8 ____ [Urban, Female, Age 21-40] Group 9 ____ [Suburban, Male, Age 21-40] Group 10 ____ [Suburban, Female, Age 41-64] Group 11 ____ [Rural, Male, Age 21-40] Group 12 ____ [Rural, Female, Age 41-64]

Academy for Educational Development

CDC Physical Activity Guidelines Formative Testing Focus Groups

CALL FROM DATABASE OR AT RANDOM

ASK TO SPEAK TO MALE/FEMALE IN THE HOUSEHOLD AGE 21 OR OLDER

RECRUIT 10 PER GROUP (FOR 6-8 TO SHOW)

Hello, I’m __________ with __________________, an independent consumer research firm. We are not selling or promoting any product or service. We are conducting a project to better understand health and wellness, and we would like to hear your views. My questions will only take a couple of minutes.

1. Do you, or does any member of your household or immediate family, work:

For a market research company or a social marketing firm _____

For an advertising agency or public relations firm _____

For the media (TV/radio/newspapers/magazines) _____

As a healthcare professional (doctor, nurse, pharmacist, dietician, nutritionist, etc.) _____

For the US Department of Health and Human Services (HHS) or any of its branches _____

As a health or physical activity educator (personal trainer, health or PE teacher, etc.) _____

[IF YES TO ANY >> TERMINATE]

2. A) Do you have any health condition that makes you limit your physical activity? For example, lung disease, diabetes, heart problems, joint, bone or muscle problems.

Yes _____

[GO TO Q3] No _____

2. To what extent do you limit your physical activity because of this problem? Do you limit your physical activity…?

TERMINATE >> A great deal _____

TERMINATE >> Some _____

Very little _____

Not at all _____

3. [IF FEMALE, ASK] Are you currently pregnant?

No _____

TERMINATE >> Yes _____

4. We are interested in speaking with people who find it easy and people who find it hard to complete medical forms. How confident are you filling out medical forms by yourself?¹ Would you say you are …?

Extremely confident_____

Quite a bit confident _____

TERMINATE >> Somewhat confident _____

TERMINATE >> A little bit confident _____

TERMINATE >> Not at all confident _____

Read aloud: The next few questions are asked in order to get a good mix of people. You may choose not to respond to these questions. If you prefer not to answer, just let me know.

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

TERMINATE >> Less than high school graduate _____

High school graduate/GED _____

Some college _____

College graduate _____

Post graduate studies or degree _____

TERMINATE >> Prefer not to answer _____

6. About how much was your total household income last year? You do not need to give me an exact number. I will read you some ranges, and you may tell me which is the closest to the total that everyone in your household brought in last year:

[Read responses aloud]

TERMINATE >> Under $25,000 _____

TERMINATE >> $25,000 - $34,999 _____

$35,000 - $49,999 _____

$50,000 - $74,999 _____

$75,000 - $100,000 _____

$101,000 - $149,999 _____

TERMINATE >> Over $150,000 _____

[DO NOT READ] TERMINATE >> Prefer not to answer _____

7. A) Please think about a typical week in the past month. During that week, how many minutes did you do moderate-intensity aerobic activity— such as fast walking, cycling for pleasure, dancing and yard work? During moderate-intensity activity, your heartbeat is faster but you would still be able to carry on a conversation comfortably.
[HELP RESPONDENT TO CALCULATE MINUTES, AS NEEDED.]

RECORD: ________ minutes of moderate activity

B) Please think about that same typical week in the past month. During that week, how many minutes did you do vigorous-intensity aerobic activity—such as running, aerobics, fast bicycling, competitive sports or heavy yard work? Vigorous-intensity activity would cause you to be too out of breath to carry on a conversation.
[HELP RESPONDENT TO CALCULATE MINUTES, AS NEEDED.]

RECORD: ________ minutes of vigorous activity

______________min. + ( ______________min. x 2 ) = ____________adjusted minutes moderate activity vigorous activity TOTAL aerobic activity

Terminate >>> 0-60 adjusted minutes _____

continue to 7C >>> 61-149 adjusted minutes _____

continue to 7C >>> 150 or more adjusted minutes _____

C) Please think about that same typical week in the past month. During that week, on how many days did you do muscle-strengthening activities—that is exercises that increase the strength of your muscles, maintain the integrity of your bones, and improve your balance, coordination, and mobility and work all the major muscle groups (legs, hips, back, abdomen, chest, shoulders and arms)? Some examples are: Push ups, Pull ups, Leg lifts, Bicep curls, Sit us, Squats, Bench press.

0 days _____

1 day _____

TERMINATE ONLY IF MORE THAN 150 ADJUSTED MINUTES >>> 2 or more days _____

8. Do you intend to be more physically active within the next 6 months?

Yes

TERMINATE >> No

10. A) What language do you speak at home?

Primarily English _____

English and another language _____

Primarily another language _____

TERMINATE >>Not ascertained _____

2. How comfortable are you speaking English in a group?

Very comfortable _____

TERMINATE >> Somewhat comfortable _____

TERMINATE >>Not at all comfortable_____

C) [BASED ON THE PHONE SCREEN THUS FAR, Does the respondent communicate in English comfortablY and competently?]

Yes _____

TERMINATE >> No _____

11. How old are you?

[RECORD AGE] _______

TERMINATE >> 20 or younger _____

[RECRUIT INTO GROUPS 1, 4, 6, 8, 9, 11] >> 21-40 _____

[RECRUIT INTO GROUPS 2, 3, 5, 7, 10, 12] >> 41- 64 _____

TERMINATE >> 65 or older _____

12. [Record gender]

[RECRUIT INTO GROUPS 1, 3, 5, 7, 9, 11] Male _____

[RECRUIT INTO GROUPS 2, 4, 6, 8, 10, 12] Female _____

13. So that we can be sure that all backgrounds are represented in the groups, please tell me which best describes your ethnic background. Are you…?

Hispanic or Latino _____

Not Hispanic or Latino _____

[Do not read] Prefer not to answer _____

14. Do you consider yourself to be…? And you can choose one or more than one response

American Indian or Alaska Native____

Asian_____

Black or African American _____

Native Hawaiian or Other Pacific Islander____

White _____

[Do not read] Prefer not to answer _____

[RECRUIT A RACIAL/ETHNIC MIX]

15. What best describes the place where you live? [READ OUT LOUD]

[RECRUIT INTO GROUPS 1, 2, 7, 8] Urban _____

[RECRUIT INTO GROUPS 3, 4, 9, 10] Suburban _____

[RECRUIT INTO GROUPS 5, 6, 11, 12] Rural _____

[RECRUIT EQUAL NUMBERS OF URBAN/SUBURBAN/RURAL PARTICIPANTS, ASSIGNING THEM TO APPROPRIATE GROUPS, AS ABOVE.]

16. Have you ever attended a focus group discussion? By that we mean an informal discussion conducted by a professional leader in which you were asked your opinions about a product, a service, or advertising?

MAX. ½ GROUP >> ASK A-C >> Yes _____

INVITE TO GROUP >> No _____

1. How many of these groups have you attended?

______________________________ [MAX. 2 EVER]

2. What was/were the topics discussed?

______________________________ [IF Physical Activity OR EXERCISE >> TERMINATE]

3. How long ago was the last one of these groups you attended?

______________________________ [MUST BE AT LEAST 6 MONTHS AGO]

[INVITE TO APPROPRIATE GROUP]

Thank you for answering all of my questions. As I said earlier, we are listening to people to learn more about what they think about health and wellness. We would like to hear your views. In order to hear them first-hand, we are holding a discussion group on [DATE] at [TIME]. The group will last about 2 hours and will be both fun and informative. No one will try to sell you anything. No one will call on you as a result of your participation. You will receive a payment of $75 for your participation. This is an important project, and we hope that you will be part of it. We can only invite about ten people to take part. May we schedule you for one of the groups?

[If yes, read ….. ]

During the session we will be reviewing some materials about physical activity. Would you be comfortable reviewing the materials and discussing them in a group situation? [IF NO >> TERMINATE]

[If yes, read ….. ]

Also, if you need glasses for reading or for watching TV, please be sure to bring them with you to the group.

NAME: _________________________________________________

ADDRESS: _________________________________________________

CITY: _________________________________________________

ZIP CODE: _________________________________________________

PHONE: (DAY) _____________________________________

(EVE) _____________________________________

(FAX) _____________________________________

(EMAIL) _____________________________________

Interviewer: ____________________

Supervisor Confirm: ____________________

1 Question 4 is a validated measure of health literacy from: Wallace LS, Rogers ES, Roskos SE, Holiday DB, and Weiss BD. 2006. “Screening Items to Identify Patients with Limited Health Literacy Skills.” Journal of General Internal Medicine; Vol. 21 (8): 874-877.

NOTE: Use the following language to “THANK AND TERMINATE” call throughout screening process: “Thank you for taking the time to answer our questions. Unfortunately, the category you fall into is currently full. If it should open back up, may we call you back?”