Screener and Moderator's Guide for In-person Focus Group

APPENDIX C:

MATERIALS FOR FOCUS GROUPS WITH MOTHERS

Table of Contents

	Page Number
Focus Group Screener	1
Consent Form	8
Moderator Guide	9
Messages to be tested (as will be seen in-person by participants)	25

1. Screener

Message Testing for CDC’s Division of Nutrition, Physical Activity and Obesity

Recruitment Screener for Focus Groups with Mothers

• Recruitment: Recruit 10 mothers for 8 participants to show for each of 8 focus groups per region (total of 80 participants in each of the 2 regions: (1) Midwest/Mid-Atlantic; (2) South). Specifically, recruit mothers with at least one child between the ages of 1 and 8 living in their homes.

Summary of recruitment per region (2 regions total)

Segmentation/Participants	Total # of focus groups per region	# of participants to recruit per focus group	Total # of participants to recruit
Overweight/Class 1 Obese Mothers	8 focus groups	10 participants/focus group (for 8 to show)	80 participants (for 64 to show)
Healthy Weight Mothers	8 focus groups	10 participants/focus group (for 8 to show)	80 participants (for 64 to show)
Total	16 focus groups	10 participants/focus group (for 8 to show)	160 participants (for 128 to show)

• Recruit a range of income levels (low to middle income)

• Recruit a mix of race/ethnicity, education level, marital status, age of children, and occupational status

• Incentive: $75 per participant

• Duration: 1.5 hours or less per focus group (+ 10 minutes for screening)

Introduction

Hello, my name is ________ and I am calling from __________________, a marketing research firm in the ________________ area. I know you receive a lot of telephone calls from telemarketers, but I assure you, this is not a sales call. I am calling today to see if you might qualify to participate in a discussion group. Everyone who is eligible and participates will receive $75 to show appreciation for your participation. The research study is sponsored by the Centers for Disease Control and Prevention, also known as the CDC. We are interested in hearing the opinions of people across the country on several health topics.

May I please ask you a few questions to see if you are eligible to participate? The questions will include topics like your health, ethnicity, and your age and that of your children. You do not have to answer anything that makes you uncomfortable. Thank you.

>>> Agreed to answer more questions:  No → Terminate  Yes →Continue

Public Reporting Burden Statement

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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0572).

Screens

1. In general, how comfortable would you say you would feel speaking with a group of people you

do not know? [READ LIST]

( ) Very comfortable Continue

( ) Comfortable Continue

( ) Neither comfortable nor uncomfortable (neutral) Terminate

( ) Uncomfortable Terminate

( ) Very uncomfortable ……………..Terminate

2. Which of the following statements best describes the language you prefer to read: [READ LIST]

1 I only read in English……………………………………………………………………….…………………… Continue

2 I am at least as comfortable reading in English as I am in another language …… Continue

3 I prefer to read in a language other than English ……………….………………………..… Terminate

3. Do you or your spouse of partner, or any other member does any member of your household, work for/as: [READ LIST]

( ) A market research company ……………….…………………………………..………………… Terminate

( ) An advertising agency or public relations firm ……………………………..……………..…… Terminate

( ) The media (TV/radio/newspapers/magazines) ……………………………..………………… Terminate

( ) A health care professional (e.g., doctor, nurse, pharmacist, dietician, etc.).……… Terminate

( ) A health care setting or a health and wellness organization (e.g., doctor’s office, clinic, hospital, health department, fitness center, etc.) ……………..…..……………. Terminate

4. What is your age? _______________ [Record age]

[Terminate if not between ages 24-49].

5. How many other people, including both adults and children, live with you in your household?

[Record: ________]

[Terminate if they live by themselves.]

5a. Are you the mother of at least one child between the ages of 1 and 8?

( ) Yes Continue

( ) No Terminate

5b. What are the ages of the children between the ages of 0 and 18 living with you at home?

Child 1 age: ______ Child 4 age: ______

Child 2 age: ______ Child 5 age: ______

Child 3 age: ______ Child 6 age: ______

[Recruit a mix of participants by age of children per group—specifically, in each group, get mix of participants that have younger children (i.e., ages 1-4) and older children (i.e., ages 5-8) within the 1 to 8 age range. Overlap is expected.]

6a. How tall are you? (without shoes) __________ feet _______________ inches (OR ___ meters)

[Refer to the weight table below to identify ranges for healthy weight, overweight, and obesity—class 1 based on the person’s height. If person is outside (lower or higher) than those ranges, terminate. Otherwise, recruit accordingly to “healthy weight” and “overweight/obese” groups if rest of criteria is met]

6b. Which of the following statements best describes your current weight)? (without shoes) [READ LIST]

[Do not read/say “healthy weight” or “overweight” (only for recruiters’ reference)]

( ) I weigh between ___ and ___ lbs/kilos [Healthy weight range]….. Continue

( ) I weigh between ___ and ___ lbs/kilos [Overweight range]….....… Continue

( ) I weigh between ___ and ___ lbs/kilos [Obese-Class 1 range]…..... Continue

( ) None of these statements apply to me……………………………………….. Terminate

Weight in Pounds (LBS)
Height (ft/in)	Healthy Weight (BMI=18.5-24.9)	Overweight (BMI=25-29.9)	Obesity- Class 1 only (BMI=30-34.9)
4'10"	89-119	120-143	144-167
4'11"	92-123	124-148	149-173
5'	95-127	128-153	154- 178
5'1"	98-132	133-158	159-184
5'2"	101-136	137-163	164-191
5'3"	105-140	141-169	170-197
5'4"	108-145	146-174	175-203
5'5"	111-149	150-179	180-210
5'6"	115-154	155-185	186-216
5'7"	118-159	160-191	192-223
5'8"	122-164	165-196	197-229
5'9"	125-168	169-202	203-236
5'10"	129-173	174-208	209-243
5'11"	133-178	179-214	215-250
6'	137-183	184-220	221-257
6'1"	140-189	190-227	228-264
6'2"	144-194	195-233	234-272
6'3"	148-199	200-239	240-279
6'4"	152-204	205-246	247-287

Source:https://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/english_bmi_calculator/bmi_calculator.html

Weight in Kilos (KG)
Height (meters)	Normal/Healthy (BMI=18.5-24.9)	Overweight (BMI=25-29.9)	Obesity- Class 1 only (BMI=30-34.9)
1.47m	40-53	54-64	65-75
1.5m	42-56	57-67	68-78
1.52m	43-57	58-69	70-80
1.55m	45-59	60-71	72-83
1.57m	46-61	62-73	74-86
1.6m	48-63	64-76	77-89
1.63m	50-66	67-79	80-92
1.65m	51-67	68-81	82-95
1.68m	53-70	71-84	85-98
1.7m	54-72	73-86	87-101
1.73m	56-74	75-89	90-104
1.75m	57-76	77-91	92-107
1.78m	59-79	80-94	95-110
1.8m	60-80	81-97	98-113
1.83m	62-83	84-100	101-117
1.85m	64-85	86-102	103-119
1.88m	66-88	89-105	106-123
1.91m	68-91	92-109	110-127
1.93m	69-92	93-111	112-130

7. Think about the most recent time you looked up health information from any source—such as the

Internet, TV, radio, newspapers, or from a doctor or other health professional. This could include

health information for yourself or related to your child/children. About how long ago was that?

[READ LIST]

( ) Days ago Continue

( ) Weeks ago Continue

( ) Months ago Continue

( ) Years ago Terminate

( ) Never Terminate

8. Which of the following categories best describe your family’s income, before taxes?¹ This is for your household’s total income from all sources before taxes. [READ LIST]

( ) Less than $30,000/yr………………………………………………………..……………………………….…Terminate

( ) $30,000 to $40,000/yr ……………………………………………………………………………...……….. Continue

( ) $40,000 to $50,000/yr ……………………………………………………………………………...……….. Continue

( ) $50,000 to $60,000/yr ……………………………………………………………………………...……….. Continue

( ) $60,000 to $70,000/yr……………………………………………………………………………...…….….. Continue

( ) More than $70,000/yr [Record: ___________] ……………………………………...…….….. Terminate

[Recruit a mix on the lower income range ($30-$50K) and the higher income range ($50-70K) for each focus group.]

9. Please indicate your race or ethnic background. Are you…?

Ethnicity:

( ) 1. Hispanic or Latino Continue

( ) 2. Not Hispanic or Latino Continue

SELECT ONE OR MORE.

Race:

( ) 1. White Continue

( ) 2. Black or African-American Continue

( ) 3. American Indian or Alaska Native Continue

( ) 4. Native Hawaiian or Other Pacific Islander Continue

( ) 5. Asian Continue

[Recruit a mix by race/ethnicity for each focus group.]

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

( ) Grade school Terminate

( ) Less than high school graduate/Some high school Continue

( ) High school graduate or completed GED Continue

( ) Some college or technical school Continue

( ) Received four-year college degree Continue

( ) Some post graduate studies …………………………………………………………………... Continue

( ) Received advanced degree (e.g., Masters, PhD) Terminate

( ) Other: _____________________ …………………………………………………………… Terminate

[Recruit a mix across focus groups. Include 3 or 4 per focus group with a four-year college degree. Anyone who indicates their highest level of education is “grade school” or who has an advanced degree should be terminated.]

11. What is your marital status?

[Partnered]

( ) Married Continue

( ) Unmarried living with a significant other Continue

[Not Partnered]

( ) Divorced Continue

( ) Widowed Continue

( ) Separated Continue

( ) Single, never been married Continue

( ) Other: ___________________ Continue

[Include a mix by marital status for each focus group—specifically,

include at least 2 individuals who are not partnered.]

12. What is your current occupational status? Would you say…?

( ) Employed full time Continue

( ) Employed part time Continue

( ) Unemployed Continue ( ) Homemaker Continue

( ) Student Continue

( ) Retired Continue

( ) Disabled Continue

( ) Other: ______________ Continue

[Aim to recruit a mix by occupational status across the focus groups.]

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(s) available] at [Time(s) available] at [location and address]. You will join up to 9 other people. The group will meet for about 90 minutes. To show appreciation for your participation you will get $75.

Scheduled Date: _____________________ Time: ______________________

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

FULL NAME ____________________________________________

ADDRESS ____________________________________________

____________________________________________

E-MAIL ____________________________________________

CELL PHONE ____________________________________________

HOME PHONE ____________________________________________

WORK PHONE ____________________________________________

I must let you know that we do consider this to be a firm commitment on your part and we really expect to see you then. We are under obligation to our client to have a specific number of participants in each group so if you discover that you must cancel, please inform us at once so that we can replace you.

We will call or email you a day or two before your session just to confirm everything. Thank you again for your time and we will see you at the group.

2. Consent Form

Identification of Project	CDC Discussion Groups
Purpose	The Centers for Disease Control and Prevention (CDC) is the sponsor of this project. FHI 360 is helping with this project. The purpose of this project is to gather feedback regarding messages related to health. It will help inform how CDC and its partners can better communicate certain health-related information to different audiences.
Procedures	We have asked you to participate in a focus group. During the discussion, you will be asked about your thoughts and opinions regarding several messages, statements or ideas related to health and to the work of CDC and its partners. The focus group will last about 90 minutes. A trained person will lead the focus group.
Information Security	We will make audio recordings of the group. In addition, some people who work on the project may listen to the recordings and may also listen during the interview. They will write a report based on their notes and the recordings. However, no one outside of this project will listen to the recordings. We will keep what you say secure to the extent permitted by law. We will NOT put your name in the report or on the recordings. We will keep the recordings in a locked cabinet. The recordings will be destroyed by December 2022.
Risks	I understand that the risks of my participation are expected to be minimal. This means that the risks are not expected to be greater than the risks a person may normally find in their daily life.
Benefits, Freedom to Withdraw, & Ability to Ask Questions	This project is not designed to help you personally. It is intended to help CDC understand how to best communicate certain health-related information to different audiences. You do not have to answer questions that you do not want to answer. You may stop at any time. You will receive $75 to show appreciation for your participation.
Contact Information of Investigators OIRE contact for concerns regarding your rights as a participant in this research	Name: Thomas Lehman Position: Associate Director of Research, Social Marketing and Communication, FHI 360 Telephone: 202-884-8863 Email: studyinfo@fhi360.org Office of International Research Ethics (OIRE) Telephone: 919-405-1445 Email: phsc@fhi360.org

My signature confirms that I have read the information on this page. I understand my rights as a participant. I agree to take part in this discussion group. I agree to have audio recordings made of the discussion and to be observed by team members. I realize that only the people working on this project will listen to the recordings. I understand that my name will NOT be used in the report or any other products. No other information that could identify me will be used either.

Signature: ________________________________________________________

Name (Please print): ________________________________________________

Date: ___________________________

3. Moderator Guide

Focus Groups with Mothers

Message Testing for CDC’s Division of Nutrition, Physical Activity, and Obesity

I. INTRODUCTION (10 Minutes)

A. Welcome: (1 minute)

• Moderator Introduction: Hello. My name is ____. I work with _____________.

• Participant Welcome: Thank you for being here today. You’re here today to take part in a focus group. It’s a discussion to find out your opinions – like a survey, but with broad, general questions. This focus group is being sponsored by the U.S. Centers for Disease Control and Prevention, also known as the CDC. We’ve asked you to be in this discussion to get your feedback on some statements, messages, or ideas related to health and the work CDC is doing related to health.

B. Procedural Details: (1 minute)

• Audio Taping: We are audio taping this discussion (please speak one at a time). The audio recordings will be used to help in writing a summary report. No one outside of this project will listen to the recordings. We will keep what you say secure to the extent permitted by law. We will NOT put your name in the report or on the recordings. We will keep the recordings in a locked cabinet. The recordings will be destroyed by December 2022.

• One-way mirror

• Restrooms (leave one at a time)

• Turn off cell phones & pagers

C. Self-introductions: (5-6 minutes)

• Self-Introduction Instructions: We’re going to go around the room briefly to allow everyone to introduce himself. And let’s do a quick warm-up exercise as we go around the table. When it’s your turn, please tell us:

• Your first name, and then tell us

• What the word “healthy” means to you?

Public Reporting Burden Statement

Public reporting burden of this collection of information is estimated to average 1.5 hours 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).

D. Discussion Overview (2 minutes)

Before we continue, I wanted to share with you a few more details about our discussion today. As I mentioned before, we would like to get your feedback on some statements, messages or ideas related to health and the work CDC is doing related to health. What you tell us today will help inform how CDC and its partners can better communicate information related to health. For example, it may help determine how CDC presents information on its website or in print materials. I personally have no part in any communications or materials from the CDC, so feel free to tell me what you really think. All of your comments, whether positive or negative, are welcome.

Do you have any questions before we get started?

II. ENVISIONING EXERCISE (5 minutes)

To start, I would like to ask you to close your eyes and imagine a healthy, vibrant [Insert City/Area name]..

1. Now, what does that look like? Describe.

[WRITE RESPONSES ON WHITE BOARD/FLIP CHART]

III. REACTIONS TO MESSAGES AND RELEVANT TERMINOLOGY

1. Obesity-related terms (6-8 minutes [~2 min/term])

Earlier we heard a little about what “healthy” means to each of you.

Now, before we look at some specific information, I would like us to talk, in general, about some other words you’ve likely heard before.

[Show each term on flip chart as it’s being discussed.]

• Term 1: Healthy Weight

1. What does “healthy weight” mean to you?

• Term 2: Overweight

2. What does “overweight” mean to you?

• Term 3: Obesity

3. What does “obesity” mean to you?

4. Does “obesity” mean something different to you than “overweight”? How so?

   1. What difference, if any, is there between how “childhood” versus “adult” obesity prevention relates to you and your family?

• Term 4: Obesity Prevention

5. Now, what do you think of when you hear the phrase “obesity prevention”?

1. How, if at all, do you see obesity prevention relating to you and your family?

2. How, if in any way, is it relevant to your community?

2. Obesity Maps (7-8 Minutes)

Now I would like to show you some information and get your reactions. Take a minute and look this over.

[Hand out 2015 adult obesity map. Give participants < 1 minute to look at.]

1. How would you sum up this map in a few words?

2. Is this information meaningful in any way to you and your family? Why/why not?

   1. [If YES] In what ways is this relevant to you and your family?

3. Was this something that you’ve seen before?

   1. [If YES] Where have you seen something like this?

4. Now, let’s look at the information for your state on the map… [Point to state and data for state]. Do you think this accurately reflects your state? Why/Why not?

5. Does this information make you want to do anything? Why/why not?

[Next, give participants the 2011 adult obesity map and give them < 1 minute to look at it—they should also keep the 2015 map for reference.]

Now I would like to show you another map. The one you just looked at is the one for 2015. The one I am handing out now is from 2011. I would like you to take a moment to look at it, and particularly look at how it compares with the 2015 map.

6. How would you sum up this map in a few words?

7. Does seeing the 2011 map with the 2015 affect in any way your thoughts or impressions about the information presented?

   1. How does seeing these maps together make you feel? Why?

   2. What, if anything, does seeing these maps together make you want to do?

[Listen for reactions related to trends of increasing obesity rates over time. If not mentioned by participants, point it out and probe for reactions].

[Hand out the youth obesity map and give them < 1 minute to review].

Before we move on, I wanted to show you another map and get your reactions.

8. How would you sum up this map in a few words?

9. Is this information meaningful in any way to you and your family? Why/why not?

10. How, if at all, is the information in this map different from the ones we looked at before?

11. Did you have a different reaction to seeing the information in this map versus the maps you saw before? If so, for what reasons?

3. 

   Message 1

   
   

   The key to achieving and maintaining a healthy weight isn’t about short-term dietary changes. It’s about a lifestyle that includes healthy eating, regular physical activity, and balancing the number of calories you consume with the number of calories your body uses.

   
   

   Staying in control of your weight contributes to good health now and as you age. By avoiding weight gain, you avoid higher risks of many chronic diseases, such as heart disease, stroke, type 2 diabetes, high blood pressure, osteoarthritis, and some forms of cancer.

   Reactions to Messages About the Relationship of Obesity to Nutrition and Physical Activity (8-10 min [4-5 min/message])

I would now like to show you or read to you several statements, messages or ideas and ask you some questions to get your thoughts on each of them.

1. How would you sum up this message in a few words?

2. Would you say this information is meaningful to you and your family? Why/why not?

   1. Does it seem like this message is talking to you and people like you or someone else?

   2. What in the message suggested it was talking to you and people like you or someone else?

3. Was this a new idea or something that you’ve heard before?

   1. [IF HEARD BEFORE] Where or who did you hear it from?

4. Are there any words or phrases here that you think are especially attention-getting or appealing? Which ones? Why?

5. Is this message believable or not? Why or why not?

6. Does this message make you want to do anything? Does this motivate you to take action? If so, what?

7. Is there anything confusing, unclear, or hard to understand?

   1. Are there any words or phrases that bother you or that you think should be said differently?

8. How could this message be improved?

   1. Is there a way to say this differently that would make you personally more likely to notice and think about the message?

Message 2

It can be difficult for children and parents to make healthy food choices and get enough physical activity when they are exposed to environments that do not support healthy habits. Places such as child care centers, schools, or communities can affect diet and activity through the foods and drinks they offer and the opportunities for physical activity they provide.

Other community factors that affect diet and physical activity include the affordability of healthy food options, peer and social supports, marketing and promotion, and policies that determine how a community is designed.

1. How would you sum up this message in a few words?

2. Would you say this information is meaningful to you and your family? Why/why not?

   1. Does it seem like this message is talking to you and people like you or someone else?

   2. What in the message suggested it was talking to you and people like you or someone else?

3. Was this a new idea or something that you’ve heard before?

   1. [IF HEARD BEFORE] Where or who did you hear it from?

4. Are there any words or phrases here that you think are especially attention-getting or appealing? Which ones? Why?

5. Is this message believable or not? Why or why not?

6. Does this message make you want to do anything? Does this motivate you to take action? If so, what?

7. Is there anything confusing, unclear, or hard to understand?

   1. Are there any words or phrases that bother you or that you think should be said differently?

8. How could this message be improved?

   1. Is there a way to say this differently that would make you personally more likely to notice and think about the message?

4. 

   Message 3

   
   

   Although the news seems to tell us otherwise, there’s no great secret to healthy eating. To help your children and family develop healthy eating habits:

   • Provide plenty of vegetables, fruits, and whole-grain products. Whole grain products include brown rice, whole wheat tortillas and whole wheat breads.

   • Include low-fat or non-fat milk or other dairy products such as low-fat or non-fat yogurt.

   • Choose lean meats, poultry, fish, lentils, and beans for protein.

   • Serve reasonably-sized portions or bring a take-home bag when eating out at your favorite restaurant.

   • Encourage your family to drink lots of water.

   • Limit juice intake and know that fruit drinks are not real juice.

   • Limit sugar-sweetened beverages such as sodas and sweet-teas to being a treat.

   • Limit consumption of added sugars.

   • Limit consumption of saturated fat. These are mainly found in foods that come from animals (such as meat and dairy), but they can also be found in most fried foods and some pre-packaged foods.

   • Take the time to read labels and ingredient lists to help you make healthier choices.

   
   

   
   

   Reactions to Nutrition and Obesity Message(s) (5-6 Minutes)

1. How would you sum up this message in a few words?

2. Would you say this information is meaningful to you and your family? Why/why not?

   1. Does it seem like this message is talking to you and people like you or someone else?

   2. What in the message suggested it was talking to you and people like you or someone else?

3. Was this a new idea or something that you’ve heard before?

   1. [IF HEARD BEFORE] Where or who did you hear it from?

4. Are there any words or phrases here that you think are especially attention-getting or appealing? Which ones? Why?

5. Is this message believable or not? Why or why not?

6. Does this message make you want to do anything? Does this motivate you to take action? If so, what?

7. Is there anything confusing, unclear, or hard to understand?

   1. Are there any words or phrases that bother you or that you think should be said differently?

8. How could this message be improved?

   1. Is there a way to say this differently that would make you personally more likely to notice and think about the message?

5. 

   Message 4

   
   

   As a parent, you can help shape your child's attitudes and behaviors toward physical activity. Throughout their lives, encourage young people to be physically active for one hour or more each day, with activities ranging from informal, active play to organized sports. Here are some ways you can do this:

   • Set a positive example by leading an active lifestyle yourself.

   • Make physical activity part of your family's daily routine by taking family walks or playing active games together.

   • Give your children equipment that encourages physical activity.

   • Take young people to places where they can be active, such as public parks, community baseball fields or basketball courts.

   • Be positive about the physical activities in which your child participates and encourage them to be interested in new activities.

   • Make physical activity fun. Fun activities can be anything your child enjoys, either structured or non-structured. Activities can range from team sports or individual sports to recreational activities such as walking, running, skating, bicycling, swimming, playground activities or free-time play.

   • Instead of watching television after dinner, encourage your child to find fun activities to do on their own or with friends and family, such as walking, playing chase or riding bikes.

   • Be safe! Always provide protective equipment such as helmets, wrist pads or knee pads and ensure that activity is age-appropriate.

   
   

   Reactions to Physical Activity and Obesity Message(s) (5-6 Minutes)

1. How would you sum up this message in a few words?

2. Would you say this information is meaningful to you and your family? Why/why not?

   1. Does it seem like this message is talking to you and people like you or someone else?

   2. What in the message suggested it was talking to you and people like you or someone else?

3. Was this a new idea or something that you’ve heard before?

   1. [IF HEARD BEFORE] Where or who did you hear it from?

4. Are there any words or phrases here that you think are especially attention-getting or appealing? Which ones? Why?

5. Is this message believable or not? Why or why not?

6. Does this message make you want to do anything? Does this motivate you to take action? If so, what?

7. Is there anything confusing, unclear, or hard to understand?

   1. Are there any words or phrases that bother you or that you think should be said differently?

8. How could this message be improved?

   1. Is there a way to say this differently that would make you personally more likely to notice and think about the message?

6. Reactions to Relevant Beliefs/Attitudes Messages (25 minutes)

1. Ranking Exercise

Next, I would like you to take a moment to read these 9 statements [Show statements on flip chart]. I am also going to give you 3 green stickers. I would like you to walk over to the flip chart and place a green sticker next to the 3 statements that are most compelling or appealing to you—in other words, the 3 that speak the most to you. You don’t have to use all stickers.

Please take a few minutes to do this while I go to the back room and check for any follow up questions about what we have discussed so far.

Relevant beliefs/attitudes statements

(for ranking exercise)

• I would like my children to have a better life than me.

• I want my children to grow into healthy adults.

• I want my family to avoid getting chronic diseases like diabetes, heart disease, and cancer.

• I want my neighborhood to be a place where my family has access to healthy foods.

• I want my neighborhood to be a place where my family has access to places to be active.

• I want my neighborhood to be a healthy place for my family and me to live.

• I want to save money for things that are important to my family.

• I want to feel good and be able to do the things my family enjoys.

• I want everyone in my family to have a long and healthy life.

• I want to teach my children how to take care of themselves so they can live healthy lives.

• I want to be a good example for my children so they know how to lead a healthy life.

• I want my children to be happy and healthy.

• I want my children to be physically and financially independent.

[Hand each participant 3 green stickers. Give them about 3 minutes to complete the exercise while you step out of the room. Have other color stickers in case someone has trouble seeing green.]

[Look at the flip chart and determine, overall, which 3 had the most green stickers. Then probe on the reasons for their selection of each of these statements.]

1. For those of you who put a [green] sticker next to the statement [read relevant belief/attitude statement], why did you give it that sticker? [Repeat question for all 3 statements]

   1. Why did this statement particularly speak to you?

2. Where there any statements here that did not speak to you at all?

These 13 statements that we included on this list perhaps represent some things you might think about when it comes to making decisions or doing things for your and your family’s health and well-being…

3. Are there other things that are particularly important to you that you would have expected to see on this list?

   1. Are there other things not on this list that generally motive you or keep you from making certain decisions or doing certain things to take care of yourself and your family?

2. Reactions to Messages

I would now like to read/show you several more messages and get your reactions. As we did before, I will give you a paper with the message and read it out loud. Then we’ll spend a few minutes discussing your thoughts about each.

Message 5, 6 & 7: TBD—Test message for belief/attitude statement that was ranked as one of the top messages (most green stickers) by the group. Repeat for the other top 1 or 2 other messages receiving the most green stickers. If time is needed, test only 2 messages and move on to next section of guide.

[NOTE: Refer to table at end of this guide for specific message to test for each top belief/attitude selected]

1. How would you sum up this message in a few words?

2. Would you say this information is meaningful to you and your family? Why/why not?

   1. Does it seem like this message is talking to you and people like you or someone else?

   2. What in the message suggested it was talking to you and people like you or someone else?

3. Was this a new idea or something that you’ve heard before?

   1. [IF HEARD BEFORE] Where or who did you hear it from?

4. Are there any words or phrases here that you think are especially attention-getting or appealing? Which ones? Why?

5. Is this message believable or not? Why or why not?

6. How well would you say this message reflects or supports the statement [insert relevant belief/attitude statement]? Why/why not?

   1. What could be changed to make it more effective?

7. Does this message make you want to do anything? Does this motivate you to take action? If so, what?

8. Is there anything confusing, unclear, or hard to understand?

   1. Are there any words or phrases that bother you or that you think should be said differently?

9. How could this message be improved?

   1. Is there a way to say this differently that would make you personally more likely to notice and think about the message?

7. Reactions to DNPAO Description (10 minutes)

Next, I’m going to give you a handout with a statement. Please follow along as I read it out loud to you. While I read this statement aloud, I would like you to mark or circle some things with the green and red markers I gave you. Specifically, use the green marker to mark the things that stand out to you in a good way—for example, things that you like, agree with, that are important to you. Use the red marker to mark the things that stand out to you in a bad way—

Message 8

[DNPAO Description]

CDC’s Division of Nutrition, Physical Activity and Obesity is at the forefront of decreasing obesity in the U. S., including contributing to the decline in obesity among children ages 2-5. However, obesity still affects almost 1 in 5 children and 1 in 3 adults, putting people at risk for high blood pressure, high cholesterol, type 2 diabetes, heart disease and certain cancers. Obesity costs the US health care system $147 billion a year and over a quarter of all Americans 17 to 24 years are too heavy to join the military. DNPAO protects the health of Americans at every stage of life by encouraging regular physical activity and good nutrition. We support the toddler eating healthy snacks and playing actively in child care, the student being able to walk to school, the mother who chooses to breastfeed, and the older adult who can walk safely and have access to healthy foods in their own neighborhood. 

for example, that is things that are confusing, dislike, or that you don’t agree with. After I read through this and you finish marking it, I’ll ask you some questions and we can discuss this statement. [Have other color markers if someone has trouble seeing red and green.]

1. How would you sum up this message in a few words?

2. Would you say this information is meaningful to you and your family? Why/why not?

1. Does it seem like this message is talking to you and people like you or someone else?

2. What in the message suggested it was talking to you and people like you or someone else?

3. Is this message believable or not? Why or why not?

Now let’s take a few minutes to discuss what you marked as you were reading the statement.

4. What words or phrases, if any, did you mark in green? Why?

1. In other words, what words or phrases, got your attention or stood out to you in a positive way? Why?

5. Now, what words or phrases, if any, did you mark in red? Why?

   1. What, if anything, did you mark as confusing, unclear, or hard to understand?

   2. What words or phrases, if any, did you mark because they bothered you or you thought should be said differently?

6. How could this message be improved?

7. Before being contacted for this discussion, had you ever heard of CDC or the Centers for Disease Control and Prevention?

   1. If yes, what did you know about the CDC before you participated in this discussion?

   2. How, if in any way, has your knowledge or impression about what CDC does changed after our discussion today?

8. How do you feel about CDC as the source of this information?

   1. What do you think [CDC] needs to know about your community?

   2. How would you want them to be involved in your community?

IV. CLOSING (3-4 minutes)

We are almost done. Before we finish, let me ask you…

1. What are some places where you might notice messages like the ones we’ve discussed today?

1. Are there some places in particular that you would be most likely to notice and pay attention to these messages?

While you think about that, I will go to the back and check for any additional questions.

Thank you again for participating in this discussion.

2. Do you have any questions for me before we conclude?

Have a nice day! [BEFORE PARTICIPANTS LEAVE, GIVE THEM HANDOUT WITH CDC INFORMATION/CDC WEBSITE URL.]

Messages related to potential beliefs/attitudes of mothers as it relates to obesity prevention/making healthy living easier for their families

Message 5, 6 & 7 (see relevant section in guide above): Test message for the beliefs/attitudes statement that ranked as the top 3 (most green stickers) by the group. If time is needed, test only 2 messages and move on to next section of guide.

Beliefs/Attitudes	Messages
I would like my children to have a better life than me.	Childhood obesity is related to psychological problems such as anxiety and depression; low self-esteem and lower self-reported quality of life; and social problems such as bullying and stigma. Consuming a healthy diet and being physically active can help children grow as well as maintain a healthy weight throughout childhood.  Kids need nutrition from foods and drinks to fuel their bodies. The kinds and amounts of food they give their bodies can directly affect how they look and feel. Also, active kids are better learners. Students who are physically active tend to have better grades, school attendance, cognitive performance (e.g., memory) and classroom behaviors (e.g., on-task behavior). Staying active and eating well can help set your children up for success now and in the future.
I want my children to grow into healthy adults.	Eating healthy and being physically active can help kids grow into healthy adults. A poor diet and physical inactivity can lead to energy imbalance (e.g., eating more calories than your body uses) and can increase the risk of a child becoming overweight or obese. Children who have obesity are more likely to become adults with obesity. Adult obesity is associated with an increased risk of a number of serious health conditions including heart disease, type 2 diabetes, and cancer.
I want my family to avoid getting chronic diseases like diabetes, heart disease, and cancer.	Good nutrition and regular physical activity are essential to keeping current and future generations of Americans healthy. People who eat a healthy diet and get enough physical activity live longer and have fewer chronic diseases, such as type 2 diabetes, heart disease, obesity, and some forms of cancer.
I want my neighborhood to be a place where my family has access to healthy foods.	It can be difficult for children and parents to make healthy food choices and get enough physical activity when they are exposed to environments that do not support healthy habits. Places such as child care centers, schools, or communities can affect diet and activity through the foods and drinks they offer and the opportunities for physical activity they provide. Other community factors that affect diet and physical activity include the affordability of healthy food options, peer and social supports, marketing and promotion, and policies that determine how a community is designed.
I want my neighborhood to be a place where my family has access to places to be active.	It can be difficult for children and parents to make healthy food choices and get enough physical activity when they are exposed to environments that do not support healthy habits. Places such as child care centers, schools, or communities can affect diet and activity through the foods and drinks they offer and the opportunities for physical activity they provide. Other community factors that affect diet and physical activity include the affordability of healthy food options, peer and social supports, marketing and promotion, and policies that determine how a community is designed.
I want my neighborhood to be a healthy place for my family and me to live.	It can be difficult for children and parents to make healthy food choices and get enough physical activity when they are exposed to environments that do not support healthy habits. Healthy neighborhoods are those designed and built to improve the quality of life for all people who live, work, worship, learn, and play within their borders – where every person is free to make choices amid a variety of healthy, available, accessible, and affordable options.
I want to save money for things that are important to my family.	Eating unhealthy and not getting enough physical activity costs money! Excess calorie intake and physical inactivity contribute to obesity. The medical costs for adults with obesity have been found to be $1,429 higher than those of normal weight.
I want to feel good and be able to do the things my family enjoys.	Staying in control of your weight contributes to good health now and as you age. In addition to improving your health, being fit and maintaining a healthy weight is likely to improve your life in other ways. For example, your general mood and self-confidence.
I want everyone in my family to have a long and healthy life.	People who eat a healthy diet and get enough physical activity live longer. By avoiding weight gain, you avoid higher risks of many chronic diseases, such as heart disease, stroke, type 2 diabetes, high blood pressure, osteoarthritis, and some forms of cancer.
I want to teach my children how to take care of themselves so they can live healthy lives.	As a parent, you can help shape your child’s attitudes and behaviors toward physical activity and what they eat so they can make healthier choices for themselves as they get older. For example, you can make physical activity part of your family’s daily routine by taking family walks or playing active games together. And, you can help children learn to be aware of what they eat by developing healthy eating habits, looking for ways to make favorite dishes healthier, and reducing calorie-rich temptations. Making fruit and vegetables available and easy to eat and limiting sugary drinks to special occasions can also help children develop healthy behaviors.
I want to be a good example for my children so they know how to lead a healthy life.	Children and adolescents should do 60 minutes (1 hour) or more of physical activity each day. Remember that children imitate adults. Start adding physical activity to your own daily routine and encourage your child to join you.
I want my children to be happy and healthy.	Obesity during childhood can have a harmful effect on the body in a variety of ways. Childhood obesity is related to: Psychological problems such as anxiety and depression. Low self-esteem and lower self-reported quality of life. Social problems such as bullying and stigma. And, children who have obesity are more likely to have: High blood pressure and high cholesterol, which are risk factors for cardiovascular disease (CVD). Increased risk of impaired glucose tolerance, insulin resistance, and type 2 diabetes. Breathing problems, such as asthma and sleep apnea. Joint problems and musculoskeletal discomfort. Fatty liver disease, gallstones, and gastro-esophageal reflux (i.e., heartburn).
I want my children to be physically and financially independent.	Children who have obesity are more likely to become adults with obesity. Adult obesity is associated with increased risk of a number of serious health conditions including heart disease, type 2 diabetes, and cancer. If children have obesity, their obesity and disease risk factors in adulthood are likely to be more severe. The medical costs for adults with obesity were $1,429 higher than those of normal weight. Also, obese adults are more likely to be discriminated against during the hiring process and perceived as having less leadership potential which could lead to greater risk of unemployment.

4. Messages to be tested (as will be shown to participants during the focus groups)

[Mothers will take part in in-person focus groups. When they arrive at the focus group facility, they will be asked to read the consent form prior to the commencement of the focus group.

Throughout the discussion, the moderator will show, on printed pieces of paper (or, in a few cases, on a flip chart) the messages being tested. These will be shown and discussed individually. Once the group is finished discussing a message, the piece of paper will be placed in the middle of the table and the next piece will be reviewed.

In the pages that follow, the messages (as will be seen by in-person participants) are presented below.]

[To be shown on flip chart]

Healthy Weight

[To be shown on flip chart]

Overweight

[To be shown on flip chart]

Obesity

[To be shown on flip chart]

Obesity Prevention

The key to achieving and maintaining a healthy weight isn’t about short-term dietary changes. It’s about a lifestyle that includes healthy eating, regular physical activity, and balancing the number of calories you consume with the number of calories your body uses.

Staying in control of your weight contributes to good health now and as you age. By avoiding weight gain, you avoid higher risks of many chronic diseases, such as heart disease, stroke, type 2 diabetes, high blood pressure, osteoarthritis, and some forms of cancer.

It can be difficult for children and parents to make healthy food choices and get enough physical activity when they are exposed to environments that do not support healthy habits. Places such as child care centers, schools, or communities can affect diet and activity through the foods and drinks they offer and the opportunities for physical activity they provide.

Other community factors that affect diet and physical activity include the affordability of healthy food options, peer and social supports, marketing and promotion, and policies that determine how a community is designed.

Although the news seems to tell us otherwise, there’s no great secret to healthy eating. To help your children and family develop healthy eating habits:

• Provide plenty of vegetables, fruits, and whole-grain products. Whole grain products include brown rice, whole wheat tortillas and whole wheat breads.

• Include low-fat or non-fat milk or other dairy products such as low-fat or non-fat yogurt.

• Choose lean meats, poultry, fish, lentils, and beans for protein.

• Serve reasonably-sized portions or bring a take-home bag when eating out at your favorite restaurant.

• Encourage your family to drink lots of water.

• Limit juice intake and know that fruit drinks are not real juice.

• Limit sugar-sweetened beverages such as sodas and sweet-teas to being a treat.

• Limit consumption of added sugars.

• Limit consumption of saturated fat. These are mainly found in foods that come from animals (such as meat and dairy), but they can also be found in most fried foods and some pre-packaged foods.

• Take the time to read labels and ingredient lists to help you make healthier choices.

As a parent, you can help shape your child's attitudes and behaviors toward physical activity. Throughout their lives, encourage young people to be physically active for one hour or more each day, with activities ranging from informal, active play to organized sports. Here are some ways you can do this:

• Set a positive example by leading an active lifestyle yourself.

• Make physical activity part of your family's daily routine by taking family walks or playing active games together.

• Give your children equipment that encourages physical activity.

• Take young people to places where they can be active, such as public parks, community baseball fields or basketball courts.

• Be positive about the physical activities in which your child participates and encourage them to be interested in new activities.

• Make physical activity fun. Fun activities can be anything your child enjoys, either structured or non-structured. Activities can range from team sports or individual sports to recreational activities such as walking, running, skating, bicycling, swimming, playground activities or free-time play.

• Instead of watching television after dinner, encourage your child to find fun activities to do on their own or with friends and family, such as walking, playing chase or riding bikes.

• Be safe! Always provide protective equipment such as helmets, wrist pads or knee pads and ensure that activity is age-appropriate.

[To be shown on flip chart]

• I would like my children to have a better life than me.

• I want my children to grow into healthy adults.

• I want my family to avoid getting chronic diseases like diabetes, heart disease, and cancer.

• I want my neighborhood to be a place where my family has access to healthy foods.

• I want my neighborhood to be a place where my family has access to places to be active.

• I want my neighborhood to be a healthy place for my family and me to live.

• I want to save money for things that are important to my family.

• I want to feel good and be able to do the things my family enjoys.

• I want everyone in my family to have a long and healthy life.

• I want to teach my children how to take care of themselves so they can live healthy lives.

• I want to be a good example for my children so they know how to lead a healthy life.

• I want my children to be happy and healthy.

• I want my children to be physically and financially independent.

Childhood obesity is related to psychological problems such as anxiety and depression; low self-esteem and lower self-reported quality of life; and social problems such as bullying and stigma.

Consuming a healthy diet and being physically active can help children grow as well as maintain a healthy weight throughout childhood. 

Kids need nutrition from foods and drinks to fuel their bodies. The kinds and amounts of food they give their bodies can directly affect how they look and feel.

Also, active kids are better learners. Students who are physically active tend to have better grades, school attendance, cognitive performance (e.g., memory) and classroom behaviors (e.g., on-task behavior).

Staying active and eating well can help set your children up for success now and in the future.

Eating healthy and being physically active can help kids grow into healthy adults.

A poor diet and physical inactivity can lead to energy imbalance (e.g., eating more calories than your body uses) and can increase the risk of a child becoming overweight or obese.

Children who have obesity are more likely to become adults with obesity. Adult obesity is associated with an increased risk of a number of serious health conditions including heart disease, type 2 diabetes, and cancer.

Good nutrition and regular physical activity are essential to keeping current and future generations of Americans healthy. People who eat a healthy diet and get enough physical activity live longer and have fewer chronic diseases, such as type 2 diabetes, heart disease, obesity, and some forms of cancer.

It can be difficult for children and parents to make healthy food choices and get enough physical activity when they are exposed to environments that do not support healthy habits. Places such as child care centers, schools, or communities can affect diet and activity through the foods and drinks they offer and the opportunities for physical activity they provide. Other community factors that affect diet and physical activity include the affordability of healthy food options, peer and social supports, marketing and promotion, and policies that determine how a community is designed.

It can be difficult for children and parents to make healthy food choices and get enough physical activity when they are exposed to environments that do not support healthy habits. Places such as child care centers, schools, or communities can affect diet and activity through the foods and drinks they offer and the opportunities for physical activity they provide. Other community factors that affect diet and physical activity include the affordability of healthy food options, peer and social supports, marketing and promotion, and policies that determine how a community is designed.

It can be difficult for children and parents to make healthy food choices and get enough physical activity when they are exposed to environments that do not support healthy habits. Healthy neighborhoods are those designed and built to improve the quality of life for all people who live, work, worship, learn, and play within their borders – where every person is free to make choices amid a variety of healthy, available, accessible, and affordable options.

Eating unhealthy and not getting enough physical activity costs money! Excess calorie intake and physical inactivity contribute to obesity. The medical costs for adults with obesity have been found to be $1,429 higher than those of normal weight.

Staying in control of your weight contributes to good health now and as you age. In addition to improving your health, being fit and maintaining a healthy weight is likely to improve your life in other ways. For example, your general mood and self-confidence.

People who eat a healthy diet and get enough physical activity live longer. By avoiding weight gain, you avoid higher risks of many chronic diseases, such as heart disease, stroke, type 2 diabetes, high blood pressure, osteoarthritis, and some forms of cancer.

As a parent, you can help shape your child’s attitudes and behaviors toward physical activity and what they eat so they can make healthier choices for themselves as they get older.

For example, you can make physical activity part of your family’s daily routine by taking family walks or playing active games together. And, you can help children learn to be aware of what they eat by developing healthy eating habits, looking for ways to make favorite dishes healthier, and reducing calorie-rich temptations. Making fruit and vegetables available and easy to eat and limiting sugary drinks to special occasions can also help children develop healthy behaviors.

Children and adolescents should do 60 minutes (1 hour) or more of physical activity each day. Remember that children imitate adults. Start adding physical activity to your own daily routine and encourage your child to join you.

Obesity during childhood can have a harmful effect on the body in a variety of ways. Childhood obesity is related to:

• Psychological problems such as anxiety and depression.

• Low self-esteem and lower self-reported quality of life.

• Social problems such as bullying and stigma.

And, children who have obesity are more likely to have:

• High blood pressure and high cholesterol, which are risk factors for cardiovascular disease (CVD).

• Increased risk of impaired glucose tolerance, insulin resistance, and type 2 diabetes.

• Breathing problems, such as asthma and sleep apnea.

• Joint problems and musculoskeletal discomfort.

• Fatty liver disease, gallstones, and gastro-esophageal reflux (i.e., heartburn).

Children who have obesity are more likely to become adults with obesity. Adult obesity is associated with increased risk of a number of serious health conditions including heart disease, type 2 diabetes, and cancer. If children have obesity, their obesity and disease risk factors in adulthood are likely to be more severe. The medical costs for adults with obesity were $1,429 higher than those of normal weight. Also, obese adults are more likely to be discriminated against during the hiring process and perceived as having less leadership potential which could lead to greater risk of unemployment.

CDC’s Division of Nutrition, Physical Activity and Obesity is at the forefront of decreasing obesity in the U. S., including contributing to the decline in obesity among children ages 2-5. However, obesity still affects almost 1 in 5 children and 1 in 3 adults, putting people at risk for high blood pressure, high cholesterol, type 2 diabetes, heart disease and certain cancers. Obesity costs the US health care system $147 billion a year and over a quarter of all Americans 17 to 24 years are too heavy to join the military. DNPAO protects the health of Americans at every stage of life by encouraging regular physical activity and good nutrition. We support the toddler eating healthy snacks and playing actively in child care, the student being able to walk to school, the mother who chooses to breastfeed, and the older adult who can walk safely and have access to healthy foods in their own neighborhood. 

1 Poverty level for a family of 5 is $28,780 (2017), Source: https://aspe.hhs.gov/poverty-guidelines; Real median income for family households is $72,165 (2015) Source: Posey, KG. (2016) Household income: 2015 American Community Survey Briefs 15:02.

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