App C Reference Set of Example Questions for Screeners

Focus Group Testing to Effectively Plan and Tailor

Cancer Prevention and Control Communication Campaigns

Appendix C

Reference Set of Example Questions to Use in Constructing

A Focus Group Screening Form

Form Approved

OMB No. 0920-XXXX

Exp. Date XX/XX/XXXX

Focus Group Testing to Effectively Plan and Tailor

Cancer Prevention and Control Communication Campaigns

Recruitment Screener

Introduction

Group Date: _______________ Group Time: __________

General Public/Health Care Provider Name: __________________________________________________________________

Address: __________________________________________________________________

City: State: ** ________

Zip: ___________________________

Day Phone: ____________________________

Evening Phone: __________________________________________

Email: _________________________________________________________________

Other contact information: __________________________________________

Hello, my name is __ I’m with _______, (insert qualitative research firm description). On behalf of the federal Centers for Disease Control and Prevention, we are planning a focus group study with (insert general public or health care providers) about (insert specific cancer communication campaign). Some people we speak with today will be invited to participate in a focus group and will receive a token of appreciation of $____, for about 120 minutes of your time. May I ask you a few questions?

Public reporting burden of this collection of information is estimated to average 3 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. An agency may not conduct or sponsor, and a person is not required to respond to a collection of informaiton unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX)

Instructions:

Use this reference set of screening questions to construct a Screening Form for each information collection or focus group. Select questions that will assist in identifying members of the target population. Questions that are not relevant to a specific target population or communication campaign should be deleted to avoid unnecessary burden to respondents.

Demographic Questions

1. Respondent gender:

1 Male

2 Female

2. Ethnicity

• Hispanic or Latino

• Not Hispanic or Latino

3. Race (respondents may select more than one response category for Race)

• White

• Black or African American

 American Indian or Alaska Native

• Asian

 Native Hawaiian or Other Pacific Islander

4. Which of the following age categories includes you?

1 Under 50 years old

2 50 - 60 years old

3 61-70 years old

4 71 – 74 years old

5 75 or older

Questions for health care providers:

2. What is your primary specialty, that is, the specialty in which you spend 50% or more of your professional time? [Recruit a mix]

 Family Practice  General Practice

 Internal Medicine: Do you have a sub-specialty? ______________

 Other (please specify): ___________________________

3. On average, how many hours per week do you currently spend in direct patient care?

 0  1 to 19  20 to 39  40 or more

4. Which best describes the setting in which you practice?

 Solo practice

 Health Maintenance Organization (HMO) or Managed Care Organization (MCO)

 Single specialty group practice

 Multi-specialty group practice

 Government health facility (e.g., VA)

 Other (please specify): ___________________________

4A. Which best describes the type of community where your primary practice is located?

[ ] Urban

[ ] Suburban

[ ] Rural

4. What percentage of your patients are over the age of 50?

 0%  1 to 19%  20 to 39%  40% or more

6. Have you ever been diagnosed with (insert specific cancer)?

 Yes  No

7. Has a close family member ever been diagnosed with (insert specific cancer)?

 Yes  No

8. For statistical purposes, may I ask:

1. What year you graduated from medical school? __________

2. And the year you were born? _________

8. Have you participated in any focus groups about (insert specific cancer) in the last six months?

[ ] NO [ ] YES

Questions for general public only

(for illustrative purposes, assume recruitment for colorectal cancer focus groups)

10. Have you or your spouse ever worked for any of the following types of organizations in a paid position?

-Doctors office, hospital, clinic, pharmaceutical or drug company

-Health department or community health agency

-Marketing, advertising or public relations agency or department

-American Cancer Society (ACS) or another cancer organization

11. Do you have any kind of health insurance to pay for routine health care?

1 Yes

If yes: Which plan or plans? _______________________________

2 No

3 Don’t know

12. Have you ever been told by a doctor that you have [READ SLOWLY] any sort of bowel disease such as colitis, inflammatory bowel disease, Crohn’s disease, colon cancer, or polyps. POLYPS ARE SMALL GROWTHS IN YOUR COLON OR RECTUM.

1 Yes: Which one/s: ________________

2 No

3 Not sure/don’t know

13. Have you, OR your mother, father, brother, sister, or child ever had colon cancer?

1 Yes

2 No

3 Not sure/don’t know

13B. Have you ever been diagnosed with any kind of cancer?

1 No

2 Not sure/don’t know

3 Yes

If yes, ask: What kind of cancer? _________________.

For “skin cancer” only, skip to Q14. For other cancers, ask:

When were you diagnosed? _______________________

14. When, if ever, was the last time you participated in a focus group?

1. Have never participated

2. Within the last 6 months: What was the topic? _____________________________

3. More than 6 months ago

15. When was your last routine check-up or physical? ______________ [Information only]

15. Thinking about the doctor visits you have had over the last 5 years, have you been tested for:

1 Diabetes or “Sugar” 1 Yes 2 No [Information Only]

2 Heart problems 1 Yes 2 No [Information Only]

3 [Ask Females only] Breast cancer 1 Yes 2 No [Information Only]

4 [Ask Males only] Prostate cancer 1 Yes 2 No [Information Only]

5 Colon cancer

1 Yes

2 No

3 Don’t know

Now I am going to ask you some questions to determine if you have had some particular medical tests. I am used to talking with people about these tests, and I hope that you will not feel awkward about my questions.

16a. Have you ever been given a test kit to check for blood in your stool – a kit which you could use at home to collect a few stool samples from the toilet, and put them on a card

1 No

2 Don’t know

3 Yes If yes:

Did you complete the test and return the card to the lab or doctor?

1 No

2 Don’t remember

3 Yes If yes:

When was the last time you completed this test?

[Record answer____________________] Note: If unknown, try to jog memory by asking: Approximately when? [Read]

1 Within 1 year or approximately a year ago

2 More than a year ago, but less than 2 years ago

3 At least 2 or more years ago

17b. Have you ever had a test for which a doctor inserted a tube in your rectum or colon?

1 No

2 Don’t know

3 Yes If yes:

Do you remember anything about the name of the test or tests? It’s OK if you’re not sure or don’t know the exact pronunciation…anything you remember about the tests or the names will help me:

Record anything the person says: ___________________________________________

[OK if they say they don’t know the name(s)]

[Read regardless of what person says] Sigmoidoscopy (SIG-MOYD-OSS-CO-PEE) is one common test. The other test is called a colonoscopy (CO-LON-OSS-CO-PEE).

Both of these tests involve a lighted tube that the doctor inserts into your rectum to view the colon. The sigmoidoscopy is often done in the doctor’s office without medication and is relatively simple. The colonscopy uses a longer tube and typically you are given medication to relax and you must be driven home by someone else. Some people confuse these tests with one in which a tube is inserted through the mouth or the nose. That’s a different test.

Now that I have explained more about these tests, do you recall whether you have ever had a colonoscopy? That is the test that uses a longer tube and typically involves some medication. Afterwards, someone else must drive you home.

1 No

2 Yes [Continue with Q below about when colonoscopy was done]

3 Not sure [Continue with Q below about when completed to see if this

jogs person memory]

Approximately, when was the last time you had a colonoscopy?

[Record answer]________________________

If unknown, try asking…Was it:

Within the last 2 years

Within the last 5 years

5 or more years ago, but less than 10 years

Longer than 10 years ago

17c. Do you recall whether you have ever had a sigmoidoscopy? The test is usually done

without medication in the doctor’s office.

1 No

2 Yes

3 Not sure

Approximately, when was the last time you had a sigmoidoscopy?

Record answer: ____________________

For responses…

Within the last year [Terminate]

Within the last 2-3 years [Terminate]

Within the last 4-5 years [Terminate]

5 or more years ago, but less than 10 [Continue]

More than 10 years [Continue]

Don’t know….Try to jog person’s memory by asking: Approximately when?

[Read] Was it…

Within the last 2 years [Terminate]

Within the last 5 years [Terminate]

5 or more years ago, but less than 10 years [Continue]

More than 10 years ago [Continue]

17d. Have you ever had an x-ray test of your colon, for which you first were given an enema through your rectum and then x-rays of your colon were taken? This usually is called a barium enema, or lower GI test. [Note: If person volunteers that he/she has had a tube down his/her throat or swallowed “chalky stuff,” before an x-ray, this is not the same test. OK to continue if test did NOT involve an enema.]

1 No

2 Yes If yes, ask: When was the last time you completed this test?

Record answer:____________________

Don’t know If unknown, ask: Approximately when?

[Read] Was it…

Within the last 2 years

Within the last 5 years

5 or more years ago, but less than 10 years

More than 10 years ago

18. What is the last grade or year of school you completed?

1 Less than high school

2. Some high school

3 Completion of high school

4 Some college

5 Completion of college

6. Post-graduate degree

19. Please stop me when I read the range that includes your total annual household income.

**Categories will be based on each city/metro region’s median household income. Goal is to recruit primarily lower to middle class participants. OK to include some people in “upper middle” income category IF they have never had any screening tests for colorectal cancer. Affluent or very rich are not desired.

1. Less than or equal to $____________

2. More than $_____________; less than or equal to $ ___________

3. More than $; less than or equal to $_____________

4. More than $____________________

INVITATION:

Thank you for answering my questions. We are convening focus groups with (insert general public or health care providers) to discuss (insert specific cancer communication campaign). I hope you will be interested in participating.

The current options are on (insert day/time) at:

Group 1: ___________PM Eastern Daylight Time --OR--

Group 2: ___________PM Eastern Daylight Time

Are you available? If YES: Record contact information on the front.

If NO, please ask:

Would you like to be contacted again about this study if additional times are scheduled?

_____ Yes: Thank you. We will contact you if we schedule additional groups.

_____No

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