0920-0572 PWD Screener for Focus Groups

OMB No. 0920- 0572

Expiration Date 08/31/2021

Brand Concept Testing
for Diabetes Self-Management Education and Support (DSMES) Services: Screeners for People with Diabetes FOCUS GROUPS

Introduction

Hello, my name is ________ and I work with FHI 360, a non-profit organization. I am calling today to see if you might qualify to participate in a 1-hour focus group about your experience with diabetes self-management education and support services. You do not need to have participated in diabetes education and support services to be eligible. This effort is sponsored by the U.S. Centers for Disease Control and Prevention, also known as the CDC. If you qualify and participate in the focus group, you will receive a $75 gift card as a thank you for participating.

May I please ask you a few questions to see if you are eligible to participate? The questions will include topics like your health, race, and age. You do not have to answer anything that makes you uncomfortable. [GO TO SCREENING QUESTIONS]

Screening Questions

1. Gender

• Male Continue

• Female Continue

2. What is your age? __________________

• Under 18 TERMINATE

• 18-44 Continue

• 45-64 Continue

• 65 or over Continue

3. Have you been diagnosed with diabetes by a healthcare provider?

• Yes Continue

• No TERMINATE

• 

  Public Reporting Statement

  Public reporting burden of this collection of information 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. 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 (0920-0572). 

  Do not know/Unsure TERMINATE

4. What type of diabetes have you been diagnosed with, Type 1 or Type 2, or some other type (such as gestational or cancer-related)?

• Type 1 Continue

• Type 2 Continue

• Gestational TERMINATE

• Other type of diabetes TERMINATE

• Do not know/Unsure TERMINATE

5. Do you, or does any member of your household or immediate family, work as a health care professional (diabetes educator, doctor, nurse, pharmacist, dietician, community health worker, etc.)?

• Yes TERMINATE

• No Continue

6. Do you, or does any member of your household or immediate family, work in a medical office, hospital, health care system, or pharmaceutical company?

• Yes TERMINATE

• No Continue

7. Overall, how comfortable would you say you are you discussing health, medical issues, and your diabetes with an interviewer and others who may be listening? [READ LIST]

• Very comfortable Continue

• Somewhat comfortable Continue

• Somewhat uncomfortable Continue

• Very uncomfortable TERMINATE

8. [all participants will be remote FG participants] To participate in the focus group you need to have access to a computer and the internet, do you have access?

• Yes CONTINUE

• No TERMINATE

• Do not know/Unsure TERMINATE

9. How much do you agree or disagree with the following statement: I believe it is important to get regular medical check-ups.

• Strongly Disagree Terminate

• Somewhat Disagree Terminate

• Neither agree nor disagree Continue

• Somewhat Agree Continue

• Strongly Agree Continue

10. Has a health care provider ever referred you to diabetes education? I am specifically referring to diabetes education where you meet with a diabetes care and education specialist in either one-on-one, in a group or online. These services help people keep on track to live well with diabetes. Diabetes care and education specialists connect people with resources to build skills, knowledge and tools to reach their goals. Sessions can be on eating healthy, checking blood sugar, being active, managing stress, and problem solving.

• Yes CONTINUE

• No CONTINUE

• Do not know/Unsure TERMINATE

11. Have you ever participated in diabetes education to which your health care provider referred you? Again, I am specifically referring to one where you meet with a diabetes care and education specialist either in a group, one-on-one or online.

• Yes CONTINUE – ASK TO SPECIFY NAME OF PROGRAM _____________

• No CONTINUE

• Do not know/Unsure CONTINUE

12. [IF YES TO Q11] Did you participate in the diabetes education within the last 24 months?

• Yes CONTINUE

• No CONTINUE

• Do not know/Unsure CONTINUE

13. [IF YES to Q11] Thinking specifically about the diabetes education you participated in, approximately how many hours of diabetes education have you received through this program?

• RECORD NUMBER OF HOURS _____________ CONTINUE

(ALLOW DON’T KNOW, NOT SURE) (RECORD NONE AS 0)

14. How long have you had diabetes?

• Less than 2 years Continue

• 2-9 years Continue

• 10 or more year Continue

15. Have you ever experienced any health problems as a result of having diabetes? For example, these may include eye problems, foot or nerve pain, kidney problems, amputations, or heart problems. [DO NOT ask them to share the specific complications they have experienced.]

• Yes CONTINUE

• No CONTINUE

16. Which of the following best describe the area where you live?

• Urban Continue

• Suburban Continue

• Rural Continue

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

• Less than high school graduate Continue

• High school graduate or completed GED Continue

• Some college or technical school Continue

• A four-year college degree or higher Continue

• Higher than a 4-year college degree (e.g., Master’s degree, PhD) Continue

• Other (specify): _____________________ TERMINATE

18. The next two questions are about your race or ethnicity. First, how do you describe your ethnicity?

• Hispanic or Latino Continue

• Not Hispanic or Latino Continue

19. How do you describe your race? (SELECT ALL THAT APPLY)

• American Indian or Alaska Native Continue

• Asian Continue

• Black or African American Continue

• Native Hawaiian or Other Pacific Islander Continue

• White Continue

TERMINATION LANGUAGE

Thank you very much for your time. You aren’t eligible for the study, so we won’t be able to include you this time. Thank you for your time and interest. Have a good day/evening.

INVITATION FOR FOCUS GROUPS

Thank you for answering my questions. You qualify to participate in this telephone/online focus group, and I would like to schedule a time for you to participate. The focus group will last no more than 1 hour, and you will receive a $75 gift card as a token of our appreciation for your participation in the focus group. The focus group will be online and you will need a computer with internet access and access to a telephone or audio connection. Do you have your calendar available so I can schedule an interview with you? [If no, either ask when a good time is to call back to schedule or you can send an email with available time and let them pick a time via email.]

What time zone are you in? (CONFIRM FOR CALENDAR APPOINTMENTS AND EMAILS SO THAT PARTICIPANT KNOWS WE WILL SEND IT ON EDT)

We are currently scheduling focus groups for the week of [insert week] at [insert times]. What time would work best for you? [wait for response]

Type of interview: ___________________________

Scheduled Date: _____________________

Time: ______________________

If you use a hearing aid or wear glasses, please remember to bring them for the discussion.

Before we hang up, let me get the correct spelling of your name, and your address and phone numbers so we can send you an email with directions and give you a reminder call the day of the group.

FULL NAME

ADDRESS

E-MAIL

CELL PHONE

We are looking forward to your participation on [DATE] at [TIME]. We are under obligation to our client to start on time. We consider your agreement today to be a commitment. If you discover that you must cancel, please inform us at once so that we can replace you.

We will email you before the focus group just to confirm everything. Thank you again for your time and we will talk with you on (DATE and TIME).

Screener People with Diabetes for DSMES Brand and Message Concept Testing 8