Form 1 Screener_Sub-study #16

OMB #0925-0046-16

Exp. Date: 1/31/2010

Attachment A: Focus Group Recruitment Screener

Project: Perceptions of Cancer among Rural Populations and the Uninsured

Client: National Cancer Institute, Office of Market Research and Evaluation

Locations/Dates:

• Based on SEER cancer mortality data, possible locations include areas in the following states:

  • Tennessee and/or Kentucky

  • Ohio and/or Indiana

  • Louisiana

  • Maine and/or Delaware

• Final sites for the focus groups will be determined later.

Recruit 10 for 6 to 8 participants to show

Public reporting burden for this collection of information is estimated to average 10 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0046-16). Do not return the completed form to this address.

[REFER TO RECRUITMENT CHART]

[Request to speak with an adult in the household between the ages of 40 and 64]

Hello, I’m _______________. I work for _____________________, an independent research firm. We are doing a research study about health issues for the National Institutes of Health or NIH. We are looking for people to take part in discussion groups. The discussions will be about topics related to cancer. Input and ideas from these discussions will help inform NIH about how to provide cancer-related information materials and educational resources to the public. We are not selling any product or service. Everyone who is eligible and participates will be paid $[amount] as a thank you for your time.

The discussion groups will be held on [Dates] at [Place] and will last about two and a half hours. I would like to ask you some questions to see if there is a discussion group that you could join. These questions will only take a few moments to answer. Do you have time now to answer a few questions?

To make sure we include a variety of people in our discussions, I’d like to ask you a few questions…

1. [RECORD SEX. DO NOT ASK]

( ) Female Continue

( ) Male Continue

(Recruit approximately half women and men)

2. What is your age?

|___|___| RECORD AGE

( ) 39 or younger Terminate

( ) 40 to 64 Continue

( ) 65 or older Terminate

( ) Refused, or any other answer Terminate

(Recruit adults ages 40-64)

3. What is the five-digit zip code of your home address?

|___|___|___|___|___| RECORD ZIP

( ) Eligible [REFER TO LIST] Continue

( ) Ineligible [REFER TO LIST] Terminate

(Recruit those living in the zip codes provided for this location)

4. What is the highest level of education you have completed? [Read responses a-f below]

( ) a. Some high school…………………………………………………………….Continue

( ) b. High school diploma/GED Continue

( ) c. Some college Continue

( ) d. College degree Continue

( ) e. Master’s degree (completed or in progress) Terminate

( ) f. PhD, JD or MD (completed or in progress) Terminate

( ) g. Refused, or any other answer Terminate

(Recruit those will a college degree or less.)

5. What is your ethnicity?

( ) Hispanic or Latino Continue

( ) Not Hispanic or Latino Continue

( ) Refused, or any other answer Terminate

6. Which of the following one or more categories best describes your race? [READ OPTIONS a-f] [CHECK ALL THAT APPLY]

( ) a. American Indian or Alaska Native Continue

( ) b. Asian Continue

( ) c. Black or African American Continue

( ) d. Native Hawaiian or Other Pacific Islander Continue

( ) e. White Continue

( ) f. Refused, or any other answer Terminate

Q6. Recruit into the following groups:

c (African American/Black) = M, N, O, P, Q, R, S, T, U, V, W, X

a, b, d, e, f (American Indian or Alaska Native, Asian, Native Hawaiian or Other Pacific Islander, or more than one category) = A, B, C, D, E, F, G, H, I, J, K, L

7. Do you currently, or have you ever worked…? (Read items a-c below. Terminate, if any apply)

( ) a. As an employee in the medical field or in the healthcare or insurance

industries Terminate

( ) b. As an employee in advertising, marketing, market research,
public relations or health promotion Terminate

( ) c. As an advocate or employee at an organization focused on
cancer such as the American Cancer Society or the
Lance Armstrong Foundation Terminate

8. Are you currently an employee of the Federal government?

( ) Yes Terminate

( ) No Continue

(Do NOT recruit those ever employed in the medical, insurance, advertising, or cancer advocacy fields, or those currently employed by the Federal government)

9. Which of the following best describes your current work schedule? (Read options a-e below.)

( ) a. Working a full-time job, that is, 35 hours or more a week…………………..……..Continue

( ) b. Working part-time for pay, totaling 20-34 hours a week........................................Continue

( ) c. Working part-time for pay, totaling fewer than 20 hours a week...........................Terminate

( ) d. Unemployed or laid off and looking for work..........................................................Continue

( ) e. Other (Specify_____________________________________) ...........................Terminate

Q9. Recruit those who are working and not working. Recruit into the following groups:

Q9 a & b (working) = A, B, D, E, G, H, J, K, M, N, P, Q, S, T, V, W

Q9 d (not working) = C, F, I, L, O, R, U, X

10. What was your total household income for the past 12 months? Please consider all income for people living in your household, including income from jobs, investments, Social Security or retirement, and welfare¹.

$ |___|___|___|___|___|___| RECORD TOTAL HOUSEHOLD INCOME

( ) No income................................................................................................ Terminate

( ) Up to $50,000.............................................................................................Continue

( ) More than $50,000.....................................................................................Terminate

11. Do you currently have any kind of health or medical insurance or are you enrolled in any kind of program that helps to pay for your health care²?

( ) Yes Continue

( ) No Continue

( ) Refused, or any other answer Continue

12. Do you have any of the following types of medical insurance...? (Read options a-g, and check all that apply.)

( ) a. Health insurance through your work (school) or a family member’s work

( ) b. Medicare – This is health insurance for people 65 or older or people with disabilities)

( ) c. Health insurance you or someone else in your family purchased directly

from an insurance company or other organization that is not related to

past or current employment

( ) d. Medicaid or [Refer to list FOR STATE PROGRAM NAMES]

( ) e. Health insurance provided as part of military service

( ) f. COBRA continuation health coverage

( ) g. Any other medical insurance? (Specify:______________________________)

[IF “NO” TO Q11 and nothing is checked in Q12 ASK Q13, OTHERWISE GO TO Q14]

13. Have you had any kind of health or medical insurance in the past 6 months?

( ) Yes Terminate

( ) No Continue

( ) Refuse, or any other answer Terminate

Q11, Q12, & Q13. Recruit those who are insured and those who are uninsured. Recruit into the following groups:

Q11 =Yes & Q12 a-e is marked (insured) =

A, D, G, J, M, P, S, V

Q11=No & Q13 = No (uninsured) =

B, C, E, F, H, I, K, L, N, O, Q, R, T, U, W, X

14. Are you, an immediate family member, or another person in your household currently coping with an illness, injury, or disease that is life-threatening? By “immediate family” I am referring to family members that include a spouse or partner, children, parents, or siblings.

( ) Yes Terminate

( ) No Continue

( ) Refuse, or any other answer Terminate

(Do NOT continue if they or their immediate family member is

currently coping with a life-threatening illness)

15. Which of the following describe your personal experiences with cancer? (Read options a-e, and check all that apply.)

( ) a. I was diagnosed with cancer Continue

( ) b. I was a caregiver to a close family member (parent, sibling, child, grandparent) with cancer ……………………………. Continue

( ) c. I was a caregiver to a close friend with cancer ……………………………………………. Continue

( ) d. No one I am close to has had cancer….…………………………………. Continue

( ) e. Refused, or any other answer Terminate

Q15. Recruit those who have personal experience with cancer and those who do not. Recruit into the following groups:

Q15=a-c is marked (personal experience with cancer) =

A, B, C, G, H, I, M, N, O, S, T, U

Q15=d is marked (no personal experience with cancer) =

D, E, F, J, K, L, P, Q, R, V, W, X

16. Would you be comfortable talking about cancer, both in general and in regard to your personal experiences, in a small group setting with both men and women?

( ) Yes……………………………………………………………………………….Continue

( ) No Terminate

( ) Refused, or any other answer Terminate

(Recruit only those who are comfortable talking about this topic)

17. Did you or the close friend or family member that you cared for have any kind of health or medical insurance while you were dealing with the cancer diagnosis?

( ) Yes (during the whole time) Terminate

( ) Yes (during part of the time) Continue

( ) No SKIP TO Q19

( ) Refused, or any other answer Continue

18. What kind of health or medical insurance did you or your close friend or family member have during the cancer diagnosis and treatment...? (Read options a-g, and check all that apply.)

( ) a. Health insurance through your/their work (school) or a family member’s work

( ) b. Medicare – This is health insurance for people 65 or older or people with disabilities)

( ) c. Health insurance you or someone else purchased directly

from an insurance company or other organization that is not related to

past or current employment

( ) d. Medicaid or [Refer to list FOR STATE PROGRAM NAMES]

( ) e. Health insurance provided as part of military service

( ) f. COBRA continuation health coverage

( ) g. Any other medical insurance? (Specify:______________________________)

19. How often over the past 6 months have you personally looked for medical or health related information? (Read options a-e below.)

( ) a. Never / Not at all Terminate

( ) b. A few times Continue

( ) c. About once a month Continue

( ) d. Several times a month Continue

( ) e. Several times a week Continue

(Recruit only those who have searched for health information in the past 6 months)

20. How often over the past 6 months have you used the Internet to search for health related information? (Read options a-e below.)

( ) a. Never / Not at all Continue

( ) b. A few times Continue

( ) c. About once a month Continue

( ) d. Several times a month Continue

( ) e. Several times a week Continue

21. What language do you speak at home? (Read options a-b below)

( ) a. Primarily English Continue

( ) b. Primarily another language Terminate

22. How comfortable are you reading and speaking English in a group? (Read options a-c below)

( ) a. Very comfortable Continue

( ) b. Somewhat comfortable Terminate

( ) c. Not at all comfortable Terminate

23. Have you participated in any research projects where you were asked to participate in a group discussion of 6-10 people with an interviewer who led the discussion?

( ) Yes Continue

( ) No Go to Invitation

24. Did you participate in any of these types of discussions in the last six months?

( ) Yes Terminate

( ) No Continue

25. What was/were the topics discussed?

____________________________________________________________________________

[Terminate if any topics ARE related to cancer OTHERWISE GO TO INVITATION]

INVITATION:

Thank you for answering my questions. I would like to tell you a little more about the discussion group. The group will meet on [Date] at [Time] at our facility in [Location]. [Give address]. You will join up to 7 other people and a moderator. The group will meet for about two and a half hours. As a thank you for your participation in the discussion you will get $[amount].

So that we can start and end on time, please come about 15 minutes early to pick up your nametag and to have some snacks. Please be sure to contact us as soon as possible if something comes up and you can't come. (Give phone number).

If you wear reading glasses or use a hearing aid, please remember to bring them with you to 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 a letter with directions and give you a reminder call the day of the group.

NAME______________________________

HOME PHONE______________________

ADDRESS ____________________________________________

____________________________________________

WORK PHONE____________CELL PHONE _________E-MAIL______________________

Thanks again for your time and we'll see you at the group!

Question 18: State names for Medicaid:

Alabama Alabama Medicaid Program

Alaska Medical Assistance Program

Arizona AHCCCS, Acute Care Program or Long Term Care System (ALTCS)

Arkansas Arkansas Medicaid

California Medi-Cal

Connecticut Connecticut Access (CONNECT CARD)

Delaware Diamond State Health Plan - Delaware's Medicaid Managed Care Program, or the

Delaware Medical Assistance Program

D.C. Medical Assistance

Florida MediPass

Georgia Better Health Care Program or Medical Assistance

Hawaii Med-QUEST, Maluhia or Medical Assistance

Idaho Healthy Connections or Medical Assistance

Illinois MediPlan

Indiana Hoosier Healthwise

Iowa MediPAS (Medical Assistance)

Kansas PrimeCare, Community Care Kansas (CCK) or HealthConnect

Kentucky Kentucky Patient Access and Care System (KenPAC) or Medical Assistance

Louisiana CommunityCARE Program

Maine PrimeCare

Maryland Maryland Access to Care (MAC) or Medical Assistance

Massachusetts MassHealth

Michigan Michigan Medicaid Health Plans

Minnesota Prepaid Medical Assistance Program (PMAP) or Health Care Programs

Mississippi HealthMACS

Missouri MC Plus

Montana Passport to Health

Nebraska Primary Care Plus (+) or Health Connection

Nevada MAPnet

New Hampshire New Hampshire Medicaid Program

New Jersey New Jersey Care 2000

New Mexico Primary Care Network

New York MAX

North Carolina Carolina Access

North Dakota North Dakota Access to Care (No DAC)

Ohio Accessing Better Care (ABC) Program

Oklahoma SoonerCare

Oregon Oregon Health Plan (OHP), Kaiser-S/HMO or Medical Assistance

Pennsylvania HealthPASS, Family Care Network (FCN), Lancaster Community Health Plan, Blue Card or Green Card or ACCESS

Rhode Island Rite Care or Medical Assistance

South Carolina South Carolina Health Access Plan (SCHAP)

South Dakota Primary Care Provider Program

Tennessee TennCare

Texas LoneSTAR (State of Texas Access Reform)

Utah Utah Medicaid Program

Vermont Dr. Dynosaur, Vermont Health Access Program (VHAP) or AIM

Virginia Medallion, Options or Medical Assistance

Washington Health Access Spokane, Kaiser-S/HMO or Healthy Options

West Virginia West Virginia Physician Assured Access System (PAAS)

Wisconsin Medical Assistance Program

Wyoming Wyoming EqualityCare

1 Real median household income in 2007 is $50,233. DeNavas-Walt, Carmen, Bernadette D. Proctor, and Jessica C. Smith, U.S. Census Bureau, Current Population Reports, P60-235, Income, Poverty, and Health Insurance Coverage in the United States: 2007, U.S. Government Printing Office, Washington, DC, 2008.

2 Q12 and Q13 are adapted from items on the 2003 National Assessment of Adult Literacy: Greenberg, E. and Jin, Y. (2007). 2003 National Assessment of Adult Literacy: Public-Use Data File User’s Guide (NCES 2007-464). U.S. Department of Education. Washington, DC: National Center for Education Statistics.

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Formative Research with Rural and Uninsured Consumers