Ethnicity & Race: Messaging to Improve Patient-Provider Communication and Engagement on Risks of Alcohol Use During Pregnancy

In-Depth Interviews with Women of Reproductive Age

Form Approved

OMB No. 0920-1154

Exp. Date: 1/31/2020

Recruiting/Screening Questionnaire

Messaging to Improve Patient-Provider Communication and Engagement on Risks of Alcohol Use During Pregnancy

Final Screener

Study Objective

Objective of Interviews:

The purpose of this study is to conduct formative research to assess perceptions among women of reproductive age regarding alcohol use during pregnancy, determine women’s comfort with discussing alcohol use, contraception (birth control), and pregnancy with their healthcare providers, and examine provider comfort with and use of alcohol screening and brief intervention (SBI).

General Composition of In-Depth Interviews

General Criteria

• The study population includes women of reproductive age (21 – 45 years of age) who drink alcohol. It includes the following groups of women:

  • Women who have never been pregnant, are not trying to get pregnant, but are sexually active and have consumed alcohol in the past 3 years.

  • Women who have never been pregnant and are trying to get pregnant and have consumed alcohol in the past 3 years.

  • Women who have had a baby in the previous year and have consumed alcohol in the past 3 years.

• Recruit six women of each group per city:

  • Chicago, IL

  • Atlanta, GA

  • Boston, MA

  • Denver, CO

General Respondent Specifications

Mix of

• Age

• Income/Education level

• Ethnic/racial background

• Do not work or have immediate family members that work or have worked in market research, advertising nor in mental health, behavioral health, and healthcare fields in the last 5 years

Messaging to Improve Patient-Provider Communication and Engagement on Risks of Alcohol Use During Pregnancy

RESPONDENT NAME:

ADDRESS:

CITY: STATE: ZIP:

TELEPHONE:

DATE RECRUITED: RECRUITED BY:

DATE CONFIRMED: CONFIRMED BY:

Hello, I’m ________________ calling from EurekaFacts in Maryland, a social science research company, on behalf of the Centers for Disease Control and Prevention. We are inviting women to discuss their views about women’s health. If you qualify for this project and complete an hour-long interview, you will receive a $40 incentive in appreciation for the completion of the interview.

You were selected to represent women just like you, and this is an opportunity to share your experiences that may result in improvements to women’s health in general. To determine if you qualify, I need to ask you a few questions. Some of the questions are about behaviors that impact your health, so they may seem personal. You can refuse to answer any questions I ask, and you can stop me from asking any more questions at any time. I’d like to start by asking a few questions now to see if you qualify.

Proceed if no objections - Continue

Objections/refusal - Thank and terminate

1. Are you comfortable participating in a discussion in English?

____Yes Continue

____No Thank and terminate

2. Which of the following age groups includes your age? Read list. Recruit a mix.

____Under 21 Thank and terminate

____21-24 Continue

____25-29 Continue

____30-39 Continue

____40-45 Continue

____Over 45 Thank and terminate

____Refused Thank and terminate

3. Are you Hispanic, Latina, or Spanish origin? Read list. Recruit a mix.

____ Yes, of Hispanic, Latina, or Spanish origin

____ No, not of Hispanic, Latina, or Spanish origin Proceed

____Refused Thank and terminate

4. What is your race? (One or more categories may be selected) Read list. Recruit a mix.

____White

____Black or African American

____American Indian or Alaska Native

____Asian

____Native Hawaiian or Other Pacific Islander Proceed

____Refused Thank and terminate

5. What was the last grade of school you completed? Read list. Recruit a mix.

____Some high school or less

____High school graduate

____Some college or less

____Graduated college

____Some graduate school

____Postgraduate or professional degree

____Refused Thank and terminate

6. Have you consumed any alcoholic drinks (wine, beer or liquor/spirits) in the past 3 years?

____Yes Continue

____No Thank and terminate

7. If yes, did you drink alcohol for any reasons other than for your religion?

____Yes Continue

____No Thank and terminate

8. Are you currently pregnant?

____Yes Thank and terminate

____No Continue

9. Have you given birth in the past 12 months?

____Yes Continue

____No Continue

10. Are you currently trying to get pregnant, or planning on getting pregnant within the next 12 months?

____Yes Continue – Women who are currently trying to get pregnant or who plan to become pregnant in the next year – GO TO OCCUPATION INELIGIBILITY Q (11)

____No Continue

11. Have you had sex, including vaginal intercourse with a male, in the past 90 days?

____Yes Continue

____No Thank and terminate

12. Thank you for answering those questions. Finally, have you, or has anyone else in your household, worked in the past five years for/in: Read list.

1. A market research, advertising, marketing or public relations firm or department of a company

2. As an independent consultant in the field of marketing, market research, advertising or public relations

3. A healthcare provider, healthcare organization, or mental or behavioral health organization or provider

4. An insurance or managed care company or health plan organization

No to A, B, C, and D Continue

Yes to A, B, C or D Thank and terminate

Refused Thank and terminate

13. Which of the following categories includes your total annual household income before taxes? Read list. Recruit a mix.

____Under $20,000 No more than 1 per group

____$20,000 to just under $29,999

____$30,000 to just under $39, 999

____$40,000 to just under $49,999

____$50,000 to just under $79,999

____$80,000 to $100,000

____$100,001 to just under $179,999

____$180,000+ No more than 2 per group

____Refused Thank and terminate

Thank you for answering these questions. You are eligible to participate in this research project. Your participation means that you will participate in a 60-minute interview and you will receive $40 for your participation at the completion of the interview.

Would you still like to participate?

IF YES – Thank you so much for your willingness to participate in the project. We will contact you to schedule the interview.

Before we hang up, let me verify the correct spelling of your first and last name, your phone number, and address so we can send you a confirmation letter with directions to the facility and give you a reminder call the day of the session. Can you please tell me your preferred method of contact? Should you have any questions, or if you are unable to attend, please contact us at <ENTER PROJECT PHONE NUMBER>.

Full Name:

Mobile Phone Number:

Home Phone Number:

Mailing Address:

Email (Required):

NOTE TO INTERVIEWER:

• Valid proof of identification to verify identity for all participants is required.

• Emphasize the amount of time (1 hour) the discussion will take and the time the discussion will take place.

• Do not schedule anyone who is reluctant about the time, is hesitant about participating in a discussion, or talks too low or speaks unclearly. That person will not be considered a valid respondent and will not be paid.

• Record respondent information on page 2 of screener (name, address and category).

In-depth Interview Screener for Women of Reproductive Age

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 information 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1154).