Health Communication Message Testing on Tuberculosis

ATTACHMENT 1A: MODERATOR’S GUIDE

OMB No. 0920-0840

Exp. Date 10/31/2021

Paperwork Reduction Act Statement: The public reporting burden for this information collection has been estimated to average 90 minutes per response, including the time to review instructions and respond to questions. 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: OMB-PRA 0920-0840.

A 90-Minute Focus Group With

Non-U.S.-Born Men and Women

at High Risk for Tuberculosis

MODERATOR’S GUIDE

Spring 2019

BACKGROUND [5 minutes]

Moderator:

• Welcome / thank you for your participation

• My name / not an employee of the Centers for Disease Control and Prevention (CDC) or the federal government / independent researcher

• My role (facilitate discussion and end on time at x:xx a.m./p.m.)

• The purpose of today’s discussion is to:

1. Discuss health conditions and diseases common in your home country and in the United States.

2. Get your feedback on information that the Centers for Disease Control and Prevention (referred to throughout as “CDC”) is developing for the general public.

3. Hear your suggestions for how CDC could best reach you with important health information.

• Some guidance for our conversation:

  • Please talk one at a time.

  • Please talk in a voice at least as loud as mine.

  • I need to hear all of your opinions—i.e., everyone should have more or less equal “air time.”

  • There are no right or wrong answers—that said, if someone disagrees with what someone else says, please speak up (we are respectful of all opinions).

  • This discussion is private—first names only / no names will be used in the summary report.

  • Your participation is voluntary (free to decline to answer a question / free to leave the room at any time).

  • I did not have anything to do with the development of the material we are going to review—if you have constructive criticism, I will not be offended or penalized.

    • Please be honest.

  • Our time together is limited—please don’t be offended if I have to interrupt you to turn to the next question; there is simply a lot to cover, and we have to finish on time.

  • If you need to leave the room, please do so one at a time.

  • Please turn your cell phones off or place them on silent.

  • We would like to audio-record this discussion so that when it comes time to write the summary report, we will have the “raw” data to turn to, as needed. Does anyone object to our audio-recording this focus group discussion? [Dismiss participant(s) if so.]

  • We will also be live video streaming this discussion so that project staff who couldn’t be here in person can view today’s discussion. The video streaming is not being recorded; thus, there will be no video record or archive of this discussion. Does anyone object to our live video streaming of this focus group discussion? [Dismiss participant(s) if so.]

  • Project staff are sitting behind the one-way mirror viewing the discussion.

PARTICIPANT INTRODUCTIONS [5 minutes]

Moderator:

• One thing everyone here has in common is you were all born in [insert country name].

(Full disclosure—I was born in [insert country name] and came to this country when I was [insert age] years old.)

Participants:

• Go around the table and have participants introduce themselves:

  1. First names only (no last names).

  2. Favorite food from your home country.

GENERAL KNOWLEDGE OF DISEASES AND TUBERCULOSIS [15 minutes]

1. Very briefly, what is one health condition or disease that concerns you greatly, and why? [Listen for tuberculosis and whether that was/is a concern in the home country and/or is a concern in the United States.]

2. What health conditions or diseases are most common in your home country?

3. How many of you have heard of “tuberculosis” (sometimes referred to as “TB”)? [Ask participants to raise hands and count out loud for the audio-recording.]

1. If you were reading a brochure or fact sheet, would you know that “TB” is short for “tuberculosis,” or would you need to see “tuberculosis” spelled out each time?

Please remember that we are not asking you to disclose your health status information. Your participation in the discussion is voluntary.

2. Among those of you who have heard of tuberculosis, please describe what tuberculosis is.

3. Where did you hear about tuberculosis/How did you learn about tuberculosis and what it is?

1. What have you heard about the TB skin test?

2. What have you heard about the TB blood test?

[If applicable for both questions: Has your health care provider told you about the test/how the test is given?]

4. Does anyone know of anyone who had or has tuberculosis?

1. What do you know about that person’s experience with tuberculosis?

5. How much of a concern is tuberculosis for you? [If needed: On a scale of 1 to 10, where 1 is “Not at All Concerned” and 10 is “Extremely Concerned,” how concerned are you about tuberculosis?][Participants to write the number on a piece of paper prior to sharing their response.]

6. How common do you think tuberculosis is? [If needed: How many people do you think get tuberculosis, out of 100 people? Or, out of 10 people?]

7. Who do you think is most likely to get tuberculosis?

8. How contagious do you think tuberculosis is? [If needed: On a scale of 1 to 10, where 1 is “Not at All Contagious” and 10 is “Extremely Contagious,” how contagious do you think tuberculosis is?]

9. How many of you have heard of “latent tuberculosis infection”? [Write on flip chart.]

1. [If no one knows what LTBI is] What do you think latent tuberculosis infection is?

2. [If applicable] Among those of you who have heard of latent tuberculosis infection, what do you know about it?

3. [If applicable] Where did you hear about latent tuberculosis infection/how did you learn about it?

EDUCATION ON TUBERCULOSIS DISEASE AND LATENT TUBERCULOSIS INFECTION

[5 minutes]

The moderator will review a brief visual PowerPoint by reading notes aloud pertaining to each slide as participants follow along.

Moderator: The reason we have gathered a group of individuals from [country of origin] is that most people diagnosed with tuberculosis disease in the United States were born in Mexico, the Philippines, India, Vietnam, China, and Guatemala. Tuberculosis rates among non-U.S.-born individuals are approximately 15 times greater than the rate among U.S.-born individuals. We will be talking more about these points as we move along in the discussion. [Moderator to read this section verbatim.]

MESSAGE TESTING [50 minutes]

The themes and messages that follow will be rotated across focus groups to ensure:

• Message testing stays within the 50-minute time allotment.

• Participants in any one focus group are not cognitively overburdened with message testing questions.

Please refer to the last two pages of this guide for the rotation of messages by audience.

Participants will review statements printed on paper and placed within a folder in front of them. The statements will be labeled in the order in which they will be discussed.

For all rating questions (e.g., On a scale of 1 to 10 where 1 is “Not at All Concerning” and 10 is “Extremely Concerning,” how important does latent TB infection seem to you?) the moderator will ask participants to write down a number on a piece of paper before sharing their response.

Moderator:

• In front of you, there is a folder that contains several statements. I am going to ask for your feedback and thoughts on these different statements. I will read a statement aloud and ask that everyone else follow along as we go.

Theme A: Basic information on latent tuberculosis infection

Statements Y, Q, and B to be discussed with participants BEFORE the moderator reviews the educational PowerPoint.

Statement Y (1): Anyone can get TB. TB germs are spread through the air from one person to another.

1. In your own words, what do you think this statement is trying to say?

2. Are there any words in this statement that you do not understand?

Statement Q (2): People who are infected with TB but are not sick have a condition called latent TB infection. 

3. In your own words, what do you think this statement is trying to say?

4. Are there any words in this statement that you do not understand?

Statement B (3): People with latent TB infection do not feel sick, do not have symptoms, and cannot spread TB germs to others. This is because the TB germs are latent, or inactive, in their body. If their TB germs become active, they can develop TB disease.

5. In your own words, what is this statement saying?

6. Are there any words in this statement that you do not understand?

   1. What does “symptoms” mean to you? What does “germs” mean to you?

7. How many of you know what the word “latent” means? [Moderator to spell out l-a-t-e-n-t.] [Show of hands.]

   1. How many of you are unsure what the word “latent” means? [Show of hands.]

   2. Can someone please define the word “latent”?

      1. What other words come to mind when you hear the word “latent”?

8. Some people find the phrase “latent TB infection” unclear. What other words or phrases would you recommend to describe the condition explained in statement B? [Probe for alternatives such as: latent tuberculosis infection, TB infection, sleeping TB, dormant TB, quiet TB, hibernating TB.]

   1. In this statement, what does “inactive” mean to you?

   2. In your folder, there is a list of other words or phrases that describe this condition. Please circle the two phrases that you find the most clear. If you have another word or phrase not on this list, write it down besides the “Other” option. [Moderator reads each term aloud.]

9. How many of you knew that if you have latent TB infection you do not feel sick? [Show of hands.]

Statement Z (4): There are two kinds of tests that are used to detect TB germs in the body: the TB skin test and the TB blood test. A person with latent TB infection has a positive TB skin test or TB blood test.

10. Tell me in your own words what this statement is trying to tell you.

11. Is anything about this statement confusing to you?

    1. What does having “a positive” TB test mean to you?

12. Are there any words or phrases in this statement that you do not understand?

Statement U (5): People can have latent TB infection for years or decades before getting sick. Many people who have latent TB infection never develop TB disease.

13. Tell me in your own words what this statement is trying to tell you.

    1. What is the difference between “latent TB infection” and “TB disease”?

14. Does anything about this statement confuse you?

15. Are there any words or phrases in this statement that you do not understand?

Statement M (6): A person with latent TB infection cannot give TB to others.

16. Tell me in your own words what this statement is trying to tell you.

17. After reading this statement, how concerning does latent TB infection seem to you? [If needed: On a scale of 1 to 10 where 1 is “Not at All Concerning” and 10 is “Extremely Concerning,” how important does latent TB infection seem to you?]

18. What could you add or change to this statement to make latent TB infection seem more important?

Statement F (7): Some people develop TB disease soon (within 2 years) after becoming infected, before their immune system can fight the TB germs. Other people may develop TB disease many years later when their immune system becomes weak for another reason.

19. In your own words, what is this statement saying?

20. Does anything about this statement confuse you?

    1. What does “immune system” mean to you? What does “germs” mean to you?

21. Are there any words or phrases in this statement that you do not understand?

Statement V (8): In the United States, up to 13 million people may have latent TB infection, according to estimates from the U.S. Centers for Disease Control and Prevention (CDC). Without treatment, they are at risk for developing TB disease.

22. After hearing that “up to 13 million people may have latent TB infection,” how common does latent TB infection seem to you?

    1. How common do you think latent TB infection is in your community? [If needed: more or less common than other communities in the United States?]

23. After hearing that people without treatment “are at risk for developing TB disease,” how concerned are you when thinking about people with latent TB infection who haven’t been treated? [If needed: On a scale of 1 to 10 where 1 is “Not at All Concerned” and 1 is “Extremely Concerned,” how concerned does this information make you feel?]

    1. Is there anything you would add to this statement to make it clearer to people that getting treatment for latent TB infection is very important? [Listen for/Probe: Adding that a person with TB disease could die if they are not treated.]

Statement X (9): One in four people worldwide may be infected with TB.

24. Of the two following statements, which one makes you think latent TB infection is big problem?

1. “One in four people worldwide may be infected with TB.” (Write on flip chart.)

2. “25 percent of people in the world may be infected with TB.” (Write on flip chart.)

Theme B: Risk factors for latent tuberculosis infection developing into tuberculosis disease

Statement Ca (10a): Without treatment, on average 1 in 10 people with latent TB infection will get sick with TB disease in the future. For some people, that risk is much higher.

25. Tell me in your own words what this statement is trying to tell you.

    1. What does “risk” mean to you?

26. How concerned does this statement make you feel about what can happen if you do not get treated for latent TB infection? [If needed: On a scale of 1 to 10 where 1 is “Not at All Concerned” and 10 is “Extremely Concerned,” how concerned does this information make you feel?]

27. Which statement is clearer to you:

• “Without treatment, on average 1 in 10 people with latent TB infection will get sick with TB disease in the future.” (Write on flip chart.)

• “Without treatment, on average 5 percent to 10 percent of people with latent TB infection will get sick with TB disease in the future.” (Write on flip chart.)

28. Which of the above statements sounds more important?

Statement Cb (10b): For those with latent TB infection, the risk for getting sick with TB disease is higher for people with HIV, diabetes, other conditions that affect their immune system, or persons receiving immunosuppressive therapy.

29. Tell me in your own words what this statement is trying to tell you.

30. Are there any words or phrases in this statement that you do not understand?

    1. What does “risk” mean to you? What does “immune system” mean to you? What does “immunosuppressive therapy” mean to you?

31. If we put the following two statements together, is it clear to you what the statements are trying to say?

    1. Statement A: Without treatment, on average 1 in 10 people with latent TB infection will get sick with TB disease in the future. For some people, that risk is much higher. The risk is higher for people with HIV, diabetes, other conditions that affect their immune system, or persons receiving immunosuppressive therapy.

Statement J (11): Some people develop TB disease soon (within 2 years) after becoming infected, before their immune system can fight the TB germs. Other people may get sick years later, even more than 10 years after they were infected, when their immune system becomes weak for another reason. This is known as reactivation of latent TB infection. 

32. In your own words, what is this statement saying?

33. Are there any words or phrases in this statement that you do not understand?

    1. What does “immune system” mean to you? What does “germs” mean to you?

    2. How many of you are familiar with the word “reactivation”?

       1. Can someone please tell me, in your own words, what the word “reactivation” means?

    3. Do you have suggestions for other words that could be used instead of “reactivation”? [Probe for: revive, activate again, awaken, wake up, become active.]

Statement P (12): Most TB disease in the United States is caused by reactivation of latent TB infection.

34. Tell me in your own words what this statement is trying to tell you.

35. Is anything about this statement confusing to you?

36. What information would help you better understand this statement?

Statement G (13): TB disease in the United States is most common among people born in countries where TB disease is more common.   

37. Tell me in your own words what this statement is trying to tell you.

38. Is anything about this statement confusing or offensive to you?

39. What do you think of when you hear “countries where TB disease is more common”?

Statement R (14a): CDC estimates that 92% of TB cases among non-U.S.–born persons are caused by reactivation of latent TB infection that was acquired in their home country, years before arrival in the United States. 

40. In your own words, what is this statement saying?

41. Is anything about this statement confusing or offensive to you?

42. Are there any words or phrases in this statement that you do not understand?

    1. What does “cases” mean to you?

43. Of the following two statements, which is clearer:

    1. CDC estimates that 92% of TB cases among non-U.S.-born persons are caused by reactivation of latent TB infection that was acquired in their home country, years before arrival in the United States. 

    2. CDC estimates that approximately 9 in 10 TB cases among non-U.S.-born persons are caused by reactivation of latent TB infection that was acquired in their home country, years before arrival in the United States. 

Statement YY (15a): CDC and the U.S. Preventive Services Task Force recommend testing populations that are at increased risk for latent TB infection, including people born in countries where TB disease is common, regardless of how long they have been in the United States.

44. Tell me in your own words what this statement is trying to tell you.

45. How does including “CDC” and “the U.S. Preventive Services Task Force” in the statement make you feel about the statement? [Probe: Does this make the statement more believable/more important?]

46. Does this statement motivate you to find out more about latent TB infection and who is at risk? Why/Why not?

    1. What would motivate you to find out more about who is at risk?

Moderator: Now, I am going to read a statement that “goes with” (accompanies) the statement we just read.

Statement YY (15b): People born in or who frequently travel to countries where TB disease is common include Mexico, the Philippines, Vietnam, India, China, Haiti, and Guatemala, or other countries with high rates of TB disease.

47. Does anything surprise you about this statement?

48. Before this focus group, how many of you knew that TB disease is common in the countries I listed, including [insert country of origin of participants]?

49. Are there any words or phrases in any of the statements that you do not understand?

50. Does this list motivate you to get tested for TB infection? Why/Why not?

51. Do these statements make you want to learn more about TB infection?

    1. What other information would you like to know about TB infection?

Theme C: Bacille Calmette-Guérin (BCG) vaccine

Statement H (16): Bacille Calmette-Guérin (BCG) is a vaccine for TB disease. This vaccine is not widely used in the United States, but it is often given to infants and small children in other countries where TB is common.

52. Tell me in your own words what this statement is trying to tell you.

53. Can someone tell me what a “vaccine” is?

54. How many of you have heard of the “Bacille Calmette-Guérin” vaccine?

    1. How about the “BCG” vaccine?

    2. [If applicable] Where did you learn about this vaccine?

    3. [If applicable] What do you know about this vaccine?

    4. How do you think the BCG vaccine affects the risks for tuberculosis?

55. If you were to read a brochure or fact sheet on this type of vaccine, what term would you be more likely to recognize:

    1. “BCG” vaccine

    2. “Bacille Calmette-Guérin” vaccine

    3. Something else? Like “TB vaccine” or “vaccine for TB”?

Statement O (17): Many people born outside of the U.S. got the BCG vaccine to protect against severe forms of TB as a child. This protection becomes weak over time.

56. Tell me in your own words what this statement is trying to tell you.

57. Does anything surprise you about this statement?

58. How believable is this statement? [If needed: On a scale of 1 to 10 where 1 is “Not at all Believable” and 10 is “Extremely Believable,” how believable is this information—specifically that protection becomes weak over time?]

    1. What else could be added to this statement to make it more believable?

59. Is anything about this statement confusing or offensive to you?

Statement NN (18): People who were vaccinated with BCG can get infected with TB and become sick with TB.

60. Tell me in your own words what this statement is trying to tell you.

61. Does anything surprise you about this statement? What questions does this statement make you want to ask?

62. How believable is this statement? [If needed: On a scale of 1 to 10 where 1 is “Not at All Believable” and 10 is “Extremely Believable,” how believable is this information—specifically that even with the BCG vaccine, someone can still become sick with tuberculosis?]

    1. What else could be added to this statement to make it more believable?

63. How motivated does this statement make you to find out more about the BCG vaccine?

    1. What else do you want to know about the BCG vaccine?

Statement XX (19): There are two kinds of tests that are used to detect TB germs in the body: the TB skin test and TB blood tests. Sometimes the BCG vaccine can cause a positive reaction to a TB skin test, even if the person is not infected with TB germs.

64. Tell me in your own words what this statement is trying to tell you.

65. Is anything about this statement confusing to you?

    1. What does it mean that the BCG vaccine can cause a positive reaction … even if the person is not infected?

66. How does this statement make you feel? [Listen for: concerned, confused, etc.]

67. Does this statement motivate you to take any action? If so, what action?

Statement AA (20): TB blood tests, unlike the TB skin test, are not affected by prior BCG vaccination.  TB blood tests are the preferred method of TB testing for people who have received the BCG vaccine.

68. Tell me in your own words what this statement is trying to tell you.

69. How likely would you be to recommend a TB blood test to a loved one who had received the BCG vaccine?

    1. What else would you need to know about the TB blood test to make this recommendation?

70. Is anything about this statement confusing to you?

    1. What does “a positive test result” mean?

    2. What does “prior BCG vaccination” mean to you?

71. Are there any words or terms in this statement that you do not understand?

72. How does this statement make you feel?

Topic D: Latent tuberculosis infection testing and diagnosis

Statement TT (21a): Anyone can get infected with TB germs. However, some people have a higher risk of getting infected with TB germs.

73. Tell me in your own words what this statement is trying to tell you.

    1. Can someone tell me in your own words what the phrase “higher risk” means in the above statement?

Moderator: Now, I am going to read four statements that “go with” (accompany) the statement we just read. Anyone can get infected with TB germs. However, some people have a higher risk of getting infected with TB germs. People who should be tested for TB infection include:

• Statement La (21b): People born in or who frequently travel to countries where TB disease is common, including Mexico, the Philippines, Vietnam, India, China, Haiti, and Guatemala, or other countries with high rates of TB disease.

• Statement Lb (21c): People who currently, or used to, live in large group settings, such as homeless shelters or prisons and jails where TB disease is more common.

• Statement Lc (21d): Health care workers and others who work in places at high risk for TB transmission, such as hospitals, homeless shelters, correctional facilities, nursing homes, and residential homes for those with HIV.

• Statement Ld (21e): Someone who has spent time with a person who has infectious TB disease.

74. Does anything surprise you about these statements?

75. Before this focus group, how many of you knew that TB disease is common in the countries I listed, including [insert country of origin of participants]?

76. Are there any words or phrases in any of statements that you do not understand?

77. Does this list motivate you to get tested for TB infection? Why/Why not?

78. Do these statements make you want to learn more about TB infection?

    1. What other information would you like to know about TB infection?

Statement ZZ (22): There are two kinds of tests that are used to detect TB germs in the body: the TB skin test and the TB blood test. The TB skin test requires two visits (one to perform the test and a second for it to be read). The TB blood test requires only a single visit to draw blood.

79. Tell me in your own words what this statement is trying to tell you.

80. Is anything about this statement confusing to you?

81. How likely would you be to go get tested for TB knowing that people born in [insert country of origin of participants] are at higher risk? [OR How likely would you be to encourage someone you love, who was also born in [country of origin], to get tested for TB?]

    1. For those of you unlikely to go get tested, what makes you not want to get tested? [Listen for: distrust in doctors, cultural barriers, transportation difficulties, lack of child care, cannot take time out of work, fear of the test’s results, no health insurance to cover costs, fear of immigration status being reported to authorities.]

    2. For those of you likely to go get tested, what test would you prefer? Why?

Statement VV (23): A positive TB skin test or TB blood test only tells that a person has been infected with TB germs. It does not tell whether the person has latent TB infection or has progressed to TB disease. More tests, like a chest x-ray, are needed to rule out TB disease.

82. Tell me in your own words what this statement is trying to tell you.

83. Is there anything about this statement that you do not understand?

84. Now, how likely are you to get tested for TB knowing that if it is “positive” you will need more tests, like a chest x-ray, to rule out TB disease? [OR: How likely would you be to encourage someone you love to get tested for TB?]

    1. If unlikely, what would motivate you to get tested?

    2. What would incentivize or encourage you to get tested no matter how many follow-up appointments it may take?

Statement BB (24): A diagnosis of latent TB infection is made if a person has a positive TB skin test or TB blood test result and a medical exam does not indicate TB disease.

85. Tell me in your own words what this statement is trying to tell you.

86. Is there anything about this statement that you do not understand?

    1. What does “a positive TB skin test or TB blood test” mean to you? What does “a diagnosis of latent TB infection” mean to you?

87. What else does this statement make you want to know about the skin test or blood test?

Topic E: Treatment for latent tuberculosis infection

Statement MM (25): People with latent TB infection do not have symptoms, are not sick with TB, and they cannot spread TB germs to others. However, if latent TB germs become active in the body and multiply, the person will go from having latent TB infection to being sick with TB disease. The good news is there are medicines people can take to treat the latent TB infection that will prevent it from developing into TB disease. This is often referred to as treatment for latent TB infection.

88. Tell me in your own words what this statement is trying to tell you.

89. Are there any words in this statement that you do not understand?

    1. In this statement, what does “active” mean to you? What about “multiply”?

90. Can someone please tell me what the word “latent” means?

    1. How many of you find this word unclear? [Ask participants to raise hands and count out loud for the audio-recording.]

91. Some people find the phrase “latent TB infection” unclear. What other words or phrases would you recommend to describe the condition explained in statement MM? [Probe for alternatives such as: latent tuberculosis infection, TB infection, sleeping TB, dormant TB, quiet TB, hibernating TB.]

92. How important do you think it is to get treated for latent TB infection?

93. How likely are you to get tested and treated for a condition if you do not feel sick?

    1. What would motivate you to get tested if you don’t feel sick?

    2. If you get tested, and find out that you test “positive” for TB germs, but still do not feel sick, how likely are you to seek treatment?

       1. What would motivate you to seek treatment?

       2. Is there anything else you would need to know about treatment before you decided to seek treatment?

       3. What would make you not want to get treated and why?

94. How much does the phrase “treatment for latent TB infection” motivate you to get treated? (What other words/phrases would you recommend to describe treatment for the TB condition where TB germs are latent, or inactive, in the body?)

    1. Do any of the following phrases make getting treatment sound more important than “treatment for latent TB infection” to you?

       1. “TB preventative therapy for latent tuberculosis infection”

       2. “Treatment for TB infection”

       3. “Chemoprophylaxis for latent tuberculosis infection”

95. Now I am going to ask you to compare two statements. Tell me which is the clearest in telling you that getting treated for latent TB infection is important, and why.

• Statement MM (26): People with latent TB infection do not have symptoms, and they cannot spread TB germs to others. However, if latent TB germs become active in the body and multiply, the person will go from having latent TB infection to being sick with TB disease. For this reason, people with latent TB infection should be treated to prevent them from developing TB disease.

• Statement UU (27): If you have a positive TB skin test or TB blood test, but do not have any other signs and symptoms of TB disease, you may have latent TB infection. If you have TB infection, you may need medicine to prevent getting TB disease later. This is called treatment for latent TB infection.

96. Now I am going to ask you to rank four statements in order of which would motivate you most to get treated for latent TB infection if you tested positive:

• Statement Da (28a): Treatment for latent TB infection is 90% effective in preventing the development of TB disease.

• Statement Db (28b): Treatment will help you stay healthy and keep those you love safe from TB.

• Statement Dc (28c): Taking your medications for latent TB infection can prevent you from developing TB disease in the future.

• Statement Dd (28d): Taking TB medication is the only way to kill the TB germs in your body.

97. Tell me why you ranked the statements (above) in the order you did.

98. Is there anything else that would motivate you to get treated?

Statement PP (29): Treatment for latent TB infection can take 3 to 9 months, depending on the regimen.

99. Tell me in your own words what this statement is trying to tell you.

100. Tell me in your own words how this statement makes you feel about treatment?

     1. What does the word “regimen” mean to you?

101. Does this statement make you unsure about getting treated? Why/Why not?

     1. If length of time to get treated (3 to 9 months) is a concern for you, what would make it less of a concern?

Statement JJ (30): Most people can take their TB medicine without any problems. However, people respond differently to medications. You could have side effects from the medicine.

102. Tell me in your own words what this statement is trying to tell you.

103. Tell me in your own words how this statement makes you feel about treatment?

     1. What does the term “side effects” mean to you? What do the terms “medication” and “medicine” mean to you?

104. Does this statement make you unsure about getting treated? Why/Why not?

105. What else would you want to know about side effects (or anything else) before deciding to get treated?

TRUSTED INFORMATION SOURCES/PREFERRED COMMUNICATION CHANNELS

[5-10 minutes]

1. Very briefly, when you need to seek health or medical care, where do you go? [Probe: clinic, health center, health department, hospital emergency room, hospital outpatient department, doctor’s office, etc.]

   1. How often do you seek health or medical care?

   2. For what purposes do you seek health or medical care?

   3. With whom do you go to seek health or medical care?

   4. What makes you more likely or less likely to seek health care? [Probe for barriers: insurance, public charge – may negatively affect immigration status]

2. What are your most trusted sources for information about health?

   1. If you were looking for information about tuberculosis, what trusted source(s) would you turn to?

      1. What websites or organizations would you trust most for information about tuberculosis?

3. If you had a question about tuberculosis, how comfortable would you feel asking your health care provider (doctor, nurse, pharmacist, clinic, hospital)?

   1. How do you communicate with your health care provider outside of in-person visits?

4. What challenges, if any, have you had communicating with your health care provider because of your language or accent? What challenges, if any, have you had with your health care provider not understanding your culture? [Probe for specifics: language/cultural barriers.]

5. If the CDC wanted to let you, and people like you, know about latent tuberculosis infection, where should they put that information? [Ask for detailed information source/communication channels: television (which stations?), radio, magazines (which ones?), newspapers, experts/providers, social media, in-person gatherings, through children’s school, through faith-based organizations, through community-based locations like the community recreational center or public library or gym, at shopping centers, etc.][Moderator to probe for responses beyond “sending emails”.]

6. If you saw information on latent tuberculosis infection and you wanted your family members, friends, colleagues, and/or neighbors to see it too, how would you share this information?

7. What is your top preferred format for receiving information on latent tuberculosis infection? [Probe: hard-copy/printed brochure/fact sheet/infographic/FAQ document; book; website; app; podcast; wallet card; blog; newsletter; website (which ones?).]

8. How important is it to you that this information be in a language other than English?

CLOSE [<5 minutes]

What I’d like to do next is ask the observers if they have any additional questions or need clarification on any of the issues we’ve discussed. [Ask any questions from observers.]

ROTATION OF THEMES AND MESSAGE STATEMENT BY AUDIENCE
Focus Group ID	Audience (by Country of Birth)	Themes	Message Statement # for Testing
1	China	Theme A: Basic information on latent tuberculosis infection (statement 1, 2 and 3 only) Theme B: Risk factors for latent tuberculosis infection developing into tuberculosis disease Theme C: Bacille Calmette-Guérin (BCG) vaccine Theme E: Treatment for latent tuberculosis infection	1–3 9–14 15–19 24–28
2	China	Theme A: Basic information on latent tuberculosis infection Theme D: Latent tuberculosis infection testing and diagnosis Theme E: Treatment for latent tuberculosis infection (exclude statement 25, similar to 3)	1–8 20–23 24; 26–28
3	Guatemala	Theme A: Basic information on latent tuberculosis infection (statement 1, 2 and 3 only) Theme B: Risk factors for latent tuberculosis infection developing into tuberculosis disease Theme C: Bacille Calmette-Guérin (BCG) vaccine Theme E: Treatment for latent tuberculosis infection	1–3 9–14 15–19 24–28
4	Guatemala	Theme A: Basic information on latent tuberculosis infection Theme D: Latent tuberculosis infection testing and diagnosis Theme E: Treatment for latent tuberculosis infection (exclude statement 25, similar to 3)	1–8 20–23 24; 26–28
5	India	Theme A: Basic information on latent tuberculosis infection (statement 1, 2 and 3 only) Theme B: Risk factors for latent tuberculosis infection developing into tuberculosis disease Theme C: Bacille Calmette-Guérin (BCG) vaccine Theme D: Latent tuberculosis infection testing and diagnosis (exclude statement 22, similar to statement 19)	1–3 9–14 15–19 20–21; 23
5	India	Theme A: Basic information on latent tuberculosis infection Theme B: Risk factors for latent tuberculosis infection developing into tuberculosis disease Theme E: Treatment for latent tuberculosis infection (exclude statement 25, similar to 3)	1–8 9–14 26–28
6	India	Theme A: Basic information on latent tuberculosis infection (exclude statement 4; similar to statement 19) Theme D: Latent tuberculosis infection testing and diagnosis Theme E: Treatment for latent tuberculosis infection	1–3; 4–8 20–23 25–28
8	Mexico	Theme A: Basic information on latent tuberculosis infection (statement 1, 2 and 3 only) Theme B: Risk factors for latent tuberculosis infection developing into tuberculosis disease Theme C: Bacille Calmette-Guérin (BCG) vaccine Theme D: Latent tuberculosis infection testing and diagnosis (exclude statement 22, similar to statement 19)	1–3 9–14 15–19 20–21; 23
9	Mexico	Theme A: Basic information on latent tuberculosis infection Theme B: Risk factors for latent tuberculosis infection developing into tuberculosis disease Theme E: Treatment for latent tuberculosis infection (exclude statement 25, similar to 3)	1–8 9–14 26–28
10	Mexico	Theme A: Basic information on latent tuberculosis infection (exclude statement 4; similar to statement 19) Theme D: Latent tuberculosis infection testing and diagnosis Theme E: Treatment for latent tuberculosis infection	1–3; 5–8 20–23 25–28
11	Philippines	Theme A: Basic information on latent tuberculosis infection (statement 1, 2 and 3 only) Theme B: Risk factors for latent tuberculosis infection developing into tuberculosis disease Theme C: Bacille Calmette-Guérin (BCG) vaccine Theme D: Latent tuberculosis infection testing and diagnosis (exclude statement 22, similar to statement 19)	1–3 9–14 15–19 20–21; 23
12	Philippines	Theme A: Basic information on latent tuberculosis infection Theme B: Risk factors for latent tuberculosis infection developing into tuberculosis disease Theme E: Treatment for latent tuberculosis infection (exclude statement 25, similar to 3)	1–8 9–14 26–28
13	Philippines	Theme A: Basic information on latent tuberculosis infection (exclude statement 4; similar to statement 19) Theme D: Latent tuberculosis infection testing and diagnosis Theme E: Treatment for latent tuberculosis infection	1–3; 5–8 20–23 25–28
14	Vietnam	Theme A: Basic information on latent tuberculosis infection (statement 1, 2 and 3 only) Theme B: Risk factors for latent tuberculosis infection developing into tuberculosis disease Theme C: Bacille Calmette-Guérin (BCG) vaccine Theme E: Treatment for latent tuberculosis infection	1–3 9–14 15–19 24–28
15	Vietnam	Theme A: Basic information on latent tuberculosis infection Theme D: Latent tuberculosis infection testing and diagnosis Theme E: Treatment for latent tuberculosis infection (exclude statement 25, similar to 3)	1–8 20–23 24; 26–28