Attachment 30. Moderator Guide English

Attachment III —Focus Group Moderator Guide Instrument in English

Form Approved OMB No. Expiration Date

Attachment 30. Moderator Guide – English

Knowledge, Attitudes, and Practices of Hispanic/Latina Women of Reproductive Age

Focus Group Moderator Guide (English)

90 minutes

Moderator instructions:

This guide will be used to steer discussion to the topic areas to be covered, and the specific questions of interest within each topic area.

For the purposes of qualitative research, it is not necessarily intended that these questions be asked exactly as they are worded here. Focus group discussions are more like a conversation than a set of structured questions. The discussion should be informal, and participants should be encouraged to speak openly and freely.

Please ensure that all participants in the group have an opportunity to express their opinions. Because each group of participants may be different, a responsive and flexible approach should be used for the focus group discussion.

The moderator will also not ask all questions in this guide--the moderator will use their judgment as to which questions to pose (and not pose) as the conversation evolves naturally. This means that some probes may be posed in some focus groups and not others.

Asterisks (*) identify priority questions and probes to ask.

Focus Group Discussion Section	Estimated Time Allotment
OPENING REMARKS	~5 minutes
ICEBREAKER: HISPANIC/LATINO IDENTITY	~5 minutes
HEALTHCARE PROVIDER EXPERIENCES	~5 minutes
VITAMINS/SUPPLEMENTS	~5 minutes
PRENATAL (AND PERINATAL) PERIOD	~3 minutes
KNOWLEDGE ON FOLIC ACID	~5 minutes
FOLIC ACID CONSUMPTION FROM VITAMINS	~10 minutes
FOOD SHOPPING/CONSUMPTION AND CORN MASA FLOUR	~20 minutes
PREGNANCY	~3 minutes
BIRTH DEFECTS	~3 minutes
BARRIERS AND FACILITATORS	~5 minutes
HISPANIC CULTURE	~5 minutes
INFORMATION SOURCES	~8 minutes
CLOSE	~5 minutes
TOTAL	90 MINUTES

Opening Remarks [~5 Minutes]

Welcome and thank you for taking part in this conversation session.

My name is <<FIRST NAME>> and I am a <<TITLE>> at EurekaFacts. I will be hosting this conversation session and <<FIRST NAME OF ASSISTING STAFF>> will be helping me with notetaking and logistics throughout this session. We have been asked by the Centers for Disease Control and Prevention, called the CDC, to learn more about the thoughts, attitudes, and practices of women like you related to certain health outcomes of women (and their children).

Each of you was invited today because the CDC wants to hear from women between the ages of 18 to 44. We want to hear your opinions and experiences on this topic as it is very important to the CDC. Your feedback today will be used to develop new health information materials for women like you. The format for today’s discussion is simple.

Participating in this conversation group is completely voluntary and will take about 90 minutes. There are no known risks or direct benefits to you from taking part or choosing not to take part. However, you might feel a little uncomfortable talking about your health experiences. This was also shared with you in the consent form that you signed earlier today.

Before we start, I would like to set a few guidelines to make our time together pleasant and productive. My job is to ask you some questions that are intended to encourage discussion (and might lead to other questions). Please remember several things:

• First, there are no right or wrong answers, just individual points of view.

• Second, we would like to hear from each of you so we know everyone’s thoughts and opinions. When you do have something to say, please do so. We want you to be open and candid about what you think and feel. Feel free to agree, disagree or add to someone else’s comment. Everyone’s perspectives will be heard and respected.

• Third, it’s okay if you don’t know an answer. Some topics might not be familiar.

• Please remember that your comments, name, and personal information will be kept confidential. No names will be used in any reports.

• Your participation is completely voluntary. You may refuse to answer any question asked during the discussion. If you are not clear about what it is that I am asking, please just let me know.

• As a courtesy to your fellow participants, we ask that you do not take outside calls during the conversation group. If you must respond to a call, please do so as quietly as possible and rejoin us as quickly as you can.

• Finally, I want to point out that we are audio recording our discussion to make sure we do not miss any of your comments. Please speak as clearly as possible and one at a time. Please be sure to use first names only. Again, EurekaFacts and the CDC will not publish or share your name or release any information that could identify you.

[Start recording]

Questions

[Moderator Instructions: Use the following questions to facilitate the conversation. Utilize the provided prompts and follow-up probes to acquire more details and clarification, as necessary.]

[Asterisks (*) identify priority questions and probes to ask]

ICEBREAKER: HISPANIC/LATINO IDENTITY [~5 minutes]

CDC is interested in understanding how people identify themselves. Spanish-speaking people or people who have Latin American heritage use different words or terms to describe people who are Spanish-speaking or who have Latin American heritage. Please tell us what word or term you like for describing yourself.

[Listen for: Hispanic, Latino, Latina, Latinx, Mestizo/a, Afro-Latino/a, Mexican, Mexican American, Salvadoran, Salvadoran American, etc.]

I will go first… [Give an example of yourself. Avoid the word “prefer” in description to not create bias. Re-introduce yourself and the term you like to use.]

1. Who would like to go next to identify themselves?

[Each probe does not need to be asked to every participant.]

• [Probe] Are there any terms you don’t like?

HEALTHCARE PROVIDER EXPERIENCES [~5 minutes]

We would like to understand where you get health services or care.

1. Where do you go for health care check-ups? How often? What is the primary reason that you go to these health care check-ups?*

2. Some women might have problems finding or getting health care. If that has happened to you, let us know what barriers you experienced while trying to get the care you need(ed).*

3. During past medical appointments (including with obstetricians/gynecologists), has your doctor or nurse talked with you about your pregnancy plans?

[PROBE] If so, when did this conversation happen? What did your doctor or nurse talk about? What sorts of things did your doctor or nurse say that you thought was helpful?

VITAMINS/SUPPLEMENTS [~5 minutes]

Now we are going to talk about vitamins. Again, it is okay if you are not familiar with the topic or have nothing to say.

1. Are any of you currently taking a (multi)vitamin or mineral supplement? (Yes/No)*

   • [IF YES] If so, what type of (multi)vitamin or mineral supplement are you taking?

   • [IF YES] Why are you taking it?

2. How do you decide what vitamins to take? Do you look for anything on the label?*

3. If you are not taking a multivitamin, what are the reasons?*

PRENATAL (AND PERINATAL) PERIOD [~3 minutes]

1. Which (multi)vitamins/mineral supplements do you think are very important to women who may become pregnant? Why?*

2. What are the benefits of taking (multi)vitamins/mineral supplements for women who are thinking about getting pregnant?*

KNOWLEDGE ON FOLIC ACID [~5 minutes]

1. What does folic acid mean to you?*

2. Have you ever read, heard, or seen anything about (vitamin) folic acid?

3. Where did you learn about vitamin folic acid?*

4. What do you think is the benefit of taking vitamin folic acid?*

5. How do you know if your vitamin contains folic acid?

FOLIC ACID CONSUMPTION FROM VITAMINS [~10 minutes]

1. Have any of you ever taken a vitamin or supplement containing vitamin folic acid before? (Yes/No/Never)*

   • [IF YES] If so, why did you start?

   • [IF YES] If you have stopped, why did you stop taking a vitamin or supplement containing folic acid?

   • [IF NO or NEVER TAKEN] This causes some curiosity, why have you not taken vitamin folic acid?*

2. Where would you get vitamins or supplements that include folic acid?*

   • [PROBE - If a retail store in the U.S.]: How do you feel about the cost of these?

3. WHEN do you think you should take vitamin folic acid? *

FOOD SHOPPING/CONSUMPTION AND CORN MASA FLOUR [~20 minutes]

Next, I’d like to talk about shopping for food products.

1. Who does most of the food shopping in your household? How often does that person shop for food? Where does that person buy food?*

2. What types of basic foods (staple foods) do you normally eat? Basic foods includes, rice products, wheat products, corn products.*

3. In your own words, what is “corn masa flour”?*

• [PROBE] Do you know if any of the foods you eat every day (or per week) are made with corn masa flour?*

• [PROBE] Do you make these foods from scratch or are they already prepared?*

  1. [IF YES] Which foods?*

In the United States and in many countries, vitamins and minerals are added to flours used in food, like corn masa. These kinds of flours (or products prepared with them) are known as “enriched” or “fortified” like breads, breakfast cereal, corn tortillas, tamales, empanadas, gorditas, pupusas, tostadas, arepas, atole, and sopes.

4. What does the word “enriched” mean to you when you see it on food packaging?*

   • [PROBE] Do you know if your country of origin enriches or fortifies food products?*

5. When shopping, do you look for products labeled enriched? (Yes/No)*

6. How do you feel about BUYING enriched foods? How do you feel about EATING foods made with enriched corn masa flour?*

[Instruction: Display visual of corn masa products.]

[Read aloud]: Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services.

• Are you familiar with the following products? (Yes/No)*

[PROBE] Where do you buy this product? *

[PROBE] What foods do you make with the <<product mentioned>>? *

[IF NEEDED: like corn tortillas, tamales, empanadas, gorditas, pupusas, tostadas, arepas, atole, and sopes]

[Instruction: Display visual of nutrition label.]

7. What do you know about nutrition labels? Do you ever look at nutrition labels?*

   • [PROBE] What do you look for when reading nutrition labels?*

   • [PROBE] Do you ever check to see if a product has folic acid in it?*

[Instruction: Collect all materials/Close slideshow]

PREGNANCY [~3 minutes]

Now we are going to talk a bit about pregnancy. Again, it is okay if you are not familiar with certain questions or have nothing to say.

1. What did you do, or would you do, to prepare for pregnancy if anything?*

• [PROBE] Who would you/did you talk to/take advice from about pregnancy/having children?

[IF NEEDED: mother, grandmother, friend (female), comadre, doula (birthing assistant), member of your community, health care provider (doctor or nurse), social media influencers. Ask for names or handles of social media influencers.]

2. If you have children, do you recall taking a vitamin or supplement containing folic acid BEFORE you were pregnant? What about WHILE you were pregnant? (Yes/No)*

• [IF YES] Where did you learn that you need to consume vitamin folic acid before (and during) pregnancy?*

BIRTH DEFECTS [~5 minutes]

1. Have you ever heard of neural tube defects or birth defects of the brain and spine, like spina bifida or anencephaly? What have you heard? *

2. Do you know anyone with one of these conditions? Or do you know anyone who has a baby with a birth defect of the brain or spine? (Yes/No)*

3. Do you think that certain women might be more at risk for having a baby with birth defects of the brain and spine? (Yes/No)*

• [PROBE] Who is at higher risk?

4. Do you think that these birth defects can be prevented? (Yes/No)*

   • [PROBE] How? [Note if vitamin is mentioned]

BARRIERS AND FACILITATORS [~5 minutes]

CDC recommends that women who can become pregnant take 400 mcg of folic acid each day to help prevent birth defects of the brain and spine.

1. What might make it hard for you to take vitamin folic acid every day?*

   • [PROBE] Cost; remembering to take it every day; belief that it will not help; belief that it will harm.

2. What might make it easier for you to take vitamin folic acid every day?*

   • [PROBE] A reminder tool; a friend/buddy; encouragement from a friend/partner; a doctor’s recommendation.

3. What would motivate you the most to start taking vitamin folic acid daily?*

HISPANIC CULTURE [~5 minutes]

As you may have gathered by now, the goal of this conversation is to gather information that you shared with us to help CDC understand current factors in how <<Latina or the preferred term used>> women make decisions on their health and obtain information. CDC wants to effectively communicate to <<Latina or the preferred term used>> women of reproductive age (18 to 44 years old) and increase their knowledge and use of folic acid to help prevent birth defects of the brain and spine.

1. What do you think would encourage <<Latina>> women who can become pregnant to take vitamin folic acid daily and/or eat enriched foods?*

   • [PROBE] What do you think CDC needs to know about the Hispanic/Latino community related to this topic?

   • [PROBE] How should we phrase this or what language should we use?

INFORMATION SOURCES [~8 minutes]

Lastly, I’d like to learn more about where you would go for health information.

1. When it comes to the topic of vitamin folic acid and the prevention of birth defects of the brain and spine, are there any organizations or people that you would really trust as a reliable source of information? What makes them trustworthy? Why?*

[Listen for/probe: government agency (federal, state, city, county); health department; school; associations; not-for-profit community organizations; community centers; YMCA; JCC.; doctor, nurse, pharmacist, curandero, religious leader/church, promotoras/community health workers, family/friends, newspaper, magazine, radio, TV, social media influencer, celebrities.]

2. What would be your preferred format for receiving more information on this topic?*

[Listen for/probe: video, podcast/audio story, fotonovela, educational pamphlet, community/public meetings, internet/websites, restaurant, supermarket, hair salon, social media, webinars, presentations.]

3. If you went looking for information on vitamin folic acid, what would you want to know or learn about?

   • [Probe] For example, would you want to know more about how to get enough folic acid or why it’s important?

CLOSE [~5 minutes]

1. Is there anything else about taking a vitamin or supplement containing folic acid that you would like to know?

This concludes today’s focus group. On behalf of CDC and EurekaFacts, I would like to thank you again for taking part in this conversation and offering your candid and important feedback.

[Stop recording]

CDC estimates the average public reporting burden for this collection of information as 90 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering, and maintaining the data/information 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 burden to CDC/ATSDR Information Collection Review Office; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (####-####).