OMB No. 0920-0572
Expiration Date 3/31/2018
Submission under
0920-0572 Health Message Testing System
Attachment 2: Consumer Message Testing for Zika Response Project
Consumer In-depth Interview Screening Instrument
Public reporting burden of 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 CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-0572)
Consumer Individual Interview Screening Instrument
Hello, my name is _______________ and I’m contacting you/calling on behalf of Abt Associates, a private research organization, and the Centers for Disease Control and Prevention.
We are not selling any product. We are contacting [INSERT TARGET POPULATION] in your area to join in an interview. The purpose of the interview is to get your honest opinions and feedback on a health education initiative. No preparation is needed for this interview.
If you are eligible and choose to participate in the interview, you will receive $25 as a token of our appreciation for participating in this interview.
To see if you are eligible to participate in the interview, we need to ask you some personal questions. It is your choice to answer these questions.
I am required to share the following information with you: There are no costs to you for being in this initiative and your participation is completely voluntary. These questions will take about 10 minutes to complete. The initiative is funded by the Centers for Disease Control and Prevention. You may refuse to answer any questions and may choose to quit at any time. The risks to you for participating in this initiative are minimal. You may experience some discomfort when answering some of the more personal questions.
We can assure you that procedures to protect the privacy of your data will be strictly followed, with your answers kept in a secure database only accessible to the researchers working on this study. If you are not eligible and/or choose not to be part of the interview, all responses you give me today will be destroyed and you will not be contacted again.
These screening questions will only take a few minutes. May I ask you the questions now?
1 Yes
0 No [END SCREENING QUESTIONS]
Procedures for Recording and Limiting Information
Note to screening staff: Only record information for the questions in the screener. If an informant reveals additional personal information, thank them for being helpful, but guide them back to the screener questions—“That is interesting to learn, but can I now ask you about. . .”
I. Demographics
What language are you most comfortable with for this interview?
1 English
2 Spanish
3 Equally comfortable in English and Spanish
4 Other [THANK AND END SCREENING]
In what ZIP Code do you currently live?
_________ [SCREENING OUT PROGRAMMING WILL DEPEND ON MARKET LOCATIONS – Locations are outlined in the main document. Activities with consumers in CONUS will focus on Texas; in particular the Lower Rio Grande Valley, and Del Rio to the Gulf (Harlingen, McAllen, Brownsville) areas.]
Have you participated in a focus group, interview, or survey in the past 6 months?
1 Yes
0 No
[ASK IF 3 = YES] 3a. What was/were the topics discussed?
______________________________________ [RECORD TOPICS]
[IF PARTICIPATED IN A FOCUS GROUP OR INTERVIEWABOUT ZIKA IN THE PAST 6 MONTHS, DETERMINE ELIGIBILITY FOR THIS DATA COLLECTION.]
4. What is your age?
__________ [RECORD AGE] [MUST BE BETWEEN 18 AND 49 YEARS; FOR ALL OTHERS, THANK AND END SCREENING]
5. What is your gender?
1 Male
2 Female
99 Prefer not to answer
[SCREENING OUT PROGRAMMING WILL DEPEND ON TARGET AUDIENCE]
Sampling plan for Consumer Interview [online]:
Target: 15 IDIs in English (n=8) and Spanish (n=7) populations. Below we present the sampling approach according to language and target audience.
Focus Groups |
||
Language |
Target |
N |
English materials |
Men in a relationship with a woman of childbearing age or pregnant woman |
4 |
Women of Childbearing age (18-49 years), non-pregnant or pregnant, in a relationship with a man |
4 |
|
Spanish Materials |
Men in a relationship with a woman of childbearing age or pregnant woman (18-49 years) |
3 |
Women of Childbearing age (18-49 years ) non-pregnant or pregnant, in a relationship with a man |
4 |
|
Total |
|
15 |
Eligibility criteria
Age 18-49 years
Gender
Zip code (screen out based on locations listed below)
Men in a relationship with a pregnant woman or woman of childbearing age (18-49)
Location: Residing in Texas - Lower Rio Grande Valley, Del Rio to the Gulf (Harlingen, McAllen, Brownsville)
6a. [ASK IF 5 = FEMALE] Are you currently pregnant?
1 Yes
0 No
88 Not sure
99 Rather not say
[SCREENING OUT PROGRAMMING WILL DEPEND ON TARGET AUDIENCE]
6b. [ASK IF 6a = YES] In what pregnancy trimester are you currently in?
1 First trimester of pregnancy (first 3 months)
2 Second trimester of pregnancy (4-6 months)
3 Third trimester of pregnancy (7-9 months)
88 Not sure
99 Rather not say
7. Which do you consider yourself to be? [READ RESPONSE OPTIONS ALOUD]
1 Gay, lesbian, homosexual, or same gender loving
2 Bisexual or two spirited
3 Straight or heterosexual
4 Other [SPECIFY:_______________]
5 None of the above/unsure
99 Prefer not to answer
8. What is your current relationship status? Are you…? [READ RESPONSE OPTIONS ALOUD; CHECK ALL THAT APPLY]
1 Single
2 Married to a man
3 Married to a woman
4 In a relationship with a man
5 In a relationship with a woman
6 Other relationship with a man
7 Other relationship with a woman
8 Divorced or widowed
99 Refused
[SCREENING OUT PROGRAMMING WILL DEPEND ON TARGET AUDIENCE]
8a. [ASK IF 8 = 3, 5, or 7] Are you currently in a relationship with a pregnant woman?
1 Yes
0 No
88 Not sure
99 Rather not say
[SCREENING OUT PROGRAMMING WILL DEPEND ON TARGET AUDIENCE]
8b. [ASK IF 8a = Yes] What pregnancy trimester is she currently in?
1 First trimester of pregnancy (first 3 months)
2 Second trimester of pregnancy (4-6 months)
3 Third trimester of pregnancy (7-9 months)
88 Not sure
99 Rather not say
9. Do you currently have any children?
0 No
1 Yes If Yes: How many children do you have? _______________
What age(s) in years?
Child 1 age: _______________
Child 2 age: _______________
Child 3 age: _______________
Child 4 age: _______________
Child 5 age: _______________
Child 6 age: _______________
Child 7 age: _______________
Child 8 age: _______________
10. What is your ethnicity?
1 Hispanic or Latino
0 Not Hispanic or Latino
99 Prefer not to answer
11. What is your race? [[SELECT ONE OR MORE CATEGORIES]
1 American Indian or Alaska Native
2 Asian
3 Black or African American
4 Native Hawaiian or Other Pacific Islander
5 White 99 Prefer not to answer
In what country were you born?
1 United States
2 United States Territory
3 Mexico
4 Cuba
5 Colombia
6 Other [SPECIFY:_______________]
9 Prefer not to answer
11a. [IF 11 = UNITED STATES] In what state were you born? ________ [SPECIFIC STATES TO BE PROGRAMED]
11b. [IF 11 = UNITED STATES TERRITORY] In what territory were you born?
1 American Samoa
2 Guam
3 Northern Mariana Islands
4 Puerto Rico
5 U.S. Virgin Islands
What best describes your current housing status [CHECK ONE]
1 Your own private house where you pay rent/mortgage
2 Your own private apartment where you pay rent/mortgage
3 A house with a roommate where you share a lease or mortgage
4 An apartment with a roommate where you share a lease or mortgage
5 A transitional house/halfway house
6 A shelter
7 On the streets/homeless
8 Other [SPECIFY:_______________]
99 Prefer not to answer
[SCREENING OUT PROGRAMMING WILL DEPEND ON TARGET AUDIENCE]
14. What is the highest grade or year of school you finished?
1 Grade school
2 Less than high school graduate/some high school
3 High school graduate / received high school diploma
[IF NO HIGH SCHOOL GRADUATION OR HIGH SCHOOL DIPLOMA:] 13a. Did you complete the GED?
1 Yes
0 No
4 Some college or technical school
5 Received four-year college degree
6 Some post graduate studies
7 Received advanced degree
8 Other [SPECIFY:_______________]
99 Prefer not to answer
[SCREENING OUT PROGRAMMING WILL DEPEND ON TARGET AUDIENCE]
15. What is your current job or employment status?
1 Employed for wages
2 Self-employed
3 Out of work and looking for work
4 Out of work but not currently looking for work
5 A homemaker
6 A student
7 Military
8 Retired
9 Unable to work
88 Not sure
99 Rather not say
15a. [ASK IF 15= 1 OR 2] Do you work for any of the following types of employers?
1 Government agency
2 Public health or health care agency
3 Marketing firm/agency
[SCREENING OUT PROGRAMMING WILL DEPEND ON TARGET AUDIENCE]
15b. [ASFK IF 15 = 1 OR 2] What is your current job title? What term would you use to describe your current profession? [OPEN] _____________________________
Which best describes your total (personal or household) income during the past year?
1 Less than $20,000
2 $20,000 to $30,000
3 $30,001 to $40,000
4 $40,001 to $50,000
5 $50,001 or more
99 Prefer not to answer
Do you currently have health insurance or health care coverage?
1 Yes
0 No
88 Don’t know
99 Prefer not to answer
Now I’m going to ask you a few sensitive questions about Zika virus. All of your answers will be kept private.
Have you ever been tested for Zika?
1 Yes
0 No
99 Prefer not to answer
18a. [IF 18 = YES] The next question is about the result of your Zika test. What was the result of your most recent Zika test?
1 I tested positive for Zika.
2 I tested negative for Zika.
3 My results were unclear.
88 I never got my results/Don’t know
99 Prefer not to answer
18b. [IF 18a = POSITIVE] When did you first test positive?
DATE (MM/YYYY):__________ [ERROR CHECK: CANNOT BE BEFORE [INSERT DATE] OR BEYOND CURRENT DATE]
88 Not sure
99 Prefer not to answer
II. Health Literacy Questions1
[THESE SCREENING QUESTIONS WILL BE USED AS NEEDED WHEN RECRUITING A LOWER LITERACY AUDIENCE OR WHEN ASSESSING HEALTH LITERACY.]
How often do you have someone (like a family member, friend, hospital/clinic worker or caregiver) help you read medical materials? [PROGRAMMING NOTE: HELP READ]
1 All of the time
2 Most of the time
3 Some of the time
4 A little of the time
5 None of the time
[SCREENING OUT PROGRAMMING WILL DEPEND ON TARGET AUDIENCE]
How often do you have problems learning about a medical condition because of difficulty understanding written information? [PROGRAMMING NOTE: PROBLEMS READING]
1 All of the time
2 Most of the time
3 Some of the time
4 A little of the time
5 None of the time
[SCREENING OUT PROGRAMMING WILL DEPEND ON TARGET AUDIENCE]
How confident are you filling out forms by yourself? [PROGRAMMING NOTE: CONFIDENT WITH FORMS]
5 Completely confident
4 Very confident
3 Somewhat confident
2 Not very confident
1 Not at all confident
[SCREENING OUT PROGRAMMING WILL DEPEND ON TARGET AUDIENCE]
Closing for Ineligible Participants:
Thank you for answering all of my questions. You are not eligible to take part in this [GROUP OR INDIVIDUAL] interview. There are many possible reasons why people are not eligible. We value your interest. Thank you for being willing to help us. If you would like more information about Zika virus infection and the current outbreak, please visit www.cdc.gov/zika.
[Do not provide reasons for ineligibility.]
Invitation:
[TEXT BELOW TO BE ADAPTED AS NEEDED FOR THE INFORMATION COLLECTION ACTIVITY.]
Based on your answers, you are eligible to participate in the interview. As I mentioned earlier, we are talking to men/women about a health condition and we would like to include your opinions. We would like to invite you to take part in [AN INTERVIEW] that will last about [INSERT 60 MINUTES FOR INTERVIEWS]. You will not be asked to buy anything. The risks to you for participating in this initiative are minimal. You may experience some discomfort when answering some of the more personal questions. You will be contacted one day before your interview to remind you of your appointment.. We can assure you that procedures to protect the privacy of your data will be strictly followed, with your answers kept in a secure database only accessible to the researchers working on this study. Any information that you provide to us will be kept private We're simply interested in your opinions. There is no preparation needed for this [INDIVIDUAL] interview.
We will be recording the interview and some project staff from Abt and CDC may be observing the interview. We may also use a live video or audio stream so project staff from Abt and CDC can observe from a computer or telephone in another location. In order to participate in the interview, you must agree to being recorded and allowing staff from the Abt and CDC to observe. As I said, if you choose to attend, whatever you say will be kept private. We will never link your name with any comment you make in the interview in any report that we write.
20. For participating in the [INTERVIEW], you will receive [REMUNERATION VALUE] as a token of our appreciation. Will you be able to join us for an [INTERVIEW]?
1 Yes [SKIP TO TEXT BELOW]
0 No (Refuse to participate) [THANK AND END]
[IF “YES” TO INVITATION, READ THE FOLLOWING STATEMENTS…]
If you need to wear glasses either for reading or watching TV, please bring them with you to the interview.
Also, we need to let you know that there will not be any childcare provided at the facility, so please make the appropriate childcare arrangements if you have children.
In order for us to send you a reminder email with directions to the interview and to call to remind you of your appointment time, I need to ask for your contact information. We will destroy this information after the interview is over.
Participant Information
Interviewer: _____________________
Date: _____________________
Call/Email/Text Reminder Date Sent: ____________________
Call/Email/Text Reconfirmation Date: ____________________ |
Name: ______________________________________________________________________
Zip code: ______________________________________________________________________
Phone 1: ____________________________ Phone 2: _____________________________
Email: ______________________________________________________________________
What is the best time to reach you? What is the best telephone number to reach you at that time? If you do not answer, may we leave a private message at that number?
Best Time to Be Reached: ________________________________________
Best Phone Number: _______________________________________
Is there another time and number we can try if we miss you?
Alternate Phone Number: ________________________________________
Your participation in this health education initiative is very important. If for some reason you will not be able to attend, please let us know right away. You can contact us anytime at [insert phone number and email address]. If no one answers the phone, please leave a message. You can also contact us if you have any questions. Thank you.
1 Chew LD, Bradley KA, Boyko EJ. Brief questions to identify patients with inadequate health literacy. Family Medicine. 2004;36(8)588–94. [PubMed] Retrieved October 27, 2016.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Cristina Booker |
| File Modified | 0000-00-00 |
| File Created | 2021-01-25 |