Mothers at Risk for Postpartum Depression

ID # __________

OWH Focus Groups: SCREENER

2022 Concept Testing for PPD Campaign

DATE __/__/____

PLEASE ASSIGN ID NUMBER TO ALL PAGES IF ELIGIBLE AND KEEP THIS PAGE AND SCREENER QUESTIONS SEPARATE.

Formatting notes: Anything in ALL CAPS or [brackets] ARE instructions for the recruiter. Anything in lower-case will be shared with potential respondents.

STATE OF RESIDENCE:

INCENTIVE AMOUNT: $100

FIRST NAME____________________________ LAST NAME___________________________

ADDRESS____________________________ CITY_______________ ZIP____________________

PHONE (HOME)______________________ (WORK/CELL)_______________________________

INTERVIEWER________________________ DATE __/__/____

EMAIL ADDRESS _____________________________________________________

INSTRUCTIONS:

Please complete each of the screener items, circling the number based on the participant response. Send the completed screener without the cover page to Wagstaff-Laura@norc.org as soon as possible. please retain the coversheet for your records separately from the screening questions. We do want screeners that include terminations so that we have data on the reasons potential respondents were not eligible. Thanks!

Hello, my name is ___________________ I am with ___________________, a marketing research firm.

On behalf of the U.S Office on Women’s Health, LTG Associates and the NORC, are recruiting women across the nation for a series of virtual online focus groups on their experiences being a new mom. The group interviews are being held for the purpose of research only. The groups will be conducted using Zoom, a free video conferencing platform. We’d like to ask you some screening questions to see if you qualify to participate. Once you complete these questions, there may be a few more questions we would like for you to complete online to place you into a group session. We will send you to an online link to complete the questions which should take about 5 minutes.

Everything you say is private. You can choose not to answer any question and you can stop the screener at any time. Your answers will be kept separate from your name and other identifying information. We assign a number to your answers instead of using your name.

1. Do you or any member of your household or a relative work for…. [CIRCLE 0=NO, 1=YES]

NO YES

1. An advertising or marketing agency 0 1

2. A market research firm or department 0 1

3. A communications or public relations firm 0 1

4. As a counselor, social worker or other mental health care setting 0 1

5. Some other mental health related job 0 1

If yes to any, THANK &TERMINATE

[TERMINATION SCRIPT]: Thank you for your time today. Unfortunately, you are not eligible for this study. We appreciate your participation. If you have questions, you can contact momshealth@norc.org. Thanks!

2. How old are you? ……………………………………………_____________ RECORD AGE

1. Less than 18 1 THANK & TERMINATE

2. 18-35 2 50% SHOULD BE BETWEEN 18- 35

3. 36–44 3 50% SHOULD BE BETWEEN 36- 44

4. 45 or Over 4 THANK & TERMINATE

5. Refused 99 THANK & TERMINATE

3. Do you currently have a child of your own under the age of 1 living in your household?

1. Yes 1 Continue

2. No 2 THANK & TERMINATE

3. Refused 3 THANK & TERMINATE

3. How many children live in your home?

1. 1 1

2. 2 2

3. 3 3

4. 4 4

5. 5 5

6. More than 5 6

AT LEAST ONE CHILD MUST BE BETWEEN 0-1, IF NOT, THANK & TERMINATE

3. I’d like to know their ages.

a. How many of the children are between the ages of 0 and 1? _____ child(ren)

b. How many of the children are between the ages of 2 and 5? _____ child(ren)

c. How many of the children are between the ages of 6 and 17? _____ child(ren)

d. How many of the children are 18 and older? _____ child(ren)

3. To make sure we are interviewing women from a variety of backgrounds and cultures, I need to ask what group or groups you identify with as your ethnic/racial heritage. I am going to read you a list of six categories. Please choose one or more races that you consider yourself to be: White/Caucasian, Black/African American, Asian, Pacific Islander, American Indian or Alaskan Native, or another category? [ALLOW MULTIPLE ANSWERS] [RECRUIT A MIX]

1. White/Caucasian 1

2. Black/African American 2

3. Asian 3

4. Pacific Islander 4

5. American Indian or Alaskan Native 5

6. Another race 6 Specify: ____________________

7. Refused 99 THANK & TERMINATE

3. I also would like to know whether you identify as Latino or Hispanic origin, such as Mexican- American, Latin American, South American, or Spanish-American?

1. Yes, Hispanic 1

2. No, Non-Hispanic 2

3. Don’t Know 77

4. Refused 99 THANK & TERMINATE

3. Also, to make sure we are balancing the locations of women across the country, I also need to ask your zip code. As a reminder, the information you provide is confidential and will not be shared outside of the research team. Your name will not be connected with the information you provide.

What is the zip code of your primary residence? _____________ RECORD ZIP CODE

3. What is the highest year of school that you have finished or gotten credit for? (IF 4 YEARS OF COLLEGE, ASK:) Did you graduate and receive a bachelor’s degree?

1. Less than High School 1

2. High School Grad, GED 2

3. Some College, AA 3

4. College Graduate (BA, BS) 4

5. Graduate Courses or Degree (Masters, PhD, DrPH) 5

3. Are you…

1. Married 1

2. Widowed 2

3. Divorced 3

4. Separated 4

5. Never married 5

3. How many people live with you? Include the people who live in your home who you share food with. Sharing food includes buying and eating meals together. You do not need to be related to the other people in your household. Include people of all ages, even children.

_________ [RECORD NUMBER OF PEOPLE]  [CONTINUE TO 12]

Refused 99 [THANK AND TERMINATE]

3. Your household’s total annual income includes income from you, your partner, or from any dependent children. It is the amount you receive before any taxes are taken out. Income can be pay for work or any other money coming in. Remember that the information you provide is confidential. Thinking about you household’s total income [GO TO SECTION B IN TABLE 1 BASED ON FAMILY SIZE FROM # 11]:

Table 1: Federal Poverty Level Data

IF FAMILY SIZE IS ____ ASK:	Do you make less than? [CIRCLE ONE Y/N]
1	$25,142	Yes No
2	$33,874	Yes No
3	$42,606	Yes No
4	$51,338	Yes No
5	$60,070	Yes No
6	$68,802	Yes No
7	$77,534	Yes No
8	$86,266	Yes No
For each additional person, add	$ 8,732	Yes No

IF REFUSED OR DON’T KNOW, THANK & TERMINATE

3. I’m going to read a few statements. After I read each one, I’d like you to tell me whether or not it describes you pretty well, not too well or not at all. READ STATEMENT AND RECORD RESPONSE IN THE APPROPRIATE COLUMNS BELOW.

Pretty Not Too Not At

Well Well All

I enjoy meeting and talking to new people

I prefer to spend all my free time at home alone* *

I think I’m creative

When I meet people for the first time, I’m shy *

and do not talk much*

I’m open about expressing my thoughts

My friends consider me friendly and outgoing

IF ELIGIBLE:

Thank you for answering my questions. We will be gathering a group of moms like you together to share their thoughts about their experience being a mom with a new baby and their feelings during this time. The session would be online using a free virtual video conferencing platform and it will last about 2 hours which will be recorded. An interviewer will ask you about your experience being a mom with your new baby and your feelings during this time. The interviewer will show you some images and text and the group will talk about them; however, the topics have the possibility to bring up sensitive emotional responses. If any uncomfortable feelings come up, you can take a break or leave at any time. We want everyone to participate in a way that makes them comfortable, and we want to know if anything we share might trigger difficult emotional responses.

You will receive $100 if you take part in the study. Do you agree to participate in the focus group session?

Yes 1

No 2  THANK & TERMINATE

As mentioned at the beginning of our conversation, we would like for you to complete a few more questions online to place you into a group. We will send you to an online link to complete the questions which should take about 5 minutes. Do you agree to complete the questions online prior to the group to help us place you into a group session?

Yes 1

No 2  THANK & TERMINATE

Once we have your information from the questions completed online, we will provide information about the group sessions and times. We will connect you with the staff from the New Mom’s Health and Wellness Study to secure a date and time for a group session. Sessions will generally be scheduled during the afternoon or evening. Do you have any questions for me at this time?

If you need help with any serious mental health or emotional concerns, or are concerned about your drug or alcohol use, call 911 in case of emergency. I also have some contact information for organizations that provide free and confidential help. Would you like for me to share that information with you at this time?

If you need to talk to someone about:	Call or text:
Feelings of depression, including Sadness or crying most of the time Feeling unconnected to your baby Not being able to take care of yourself, including sleeping, eating, or bathing	Postpartum Support International 1-800-944-4PPD (4773) and leave a message. A volunteer will call back as soon as possible
Getting help with a mental health condition Getting help with drug or alcohol use	Substance Abuse and Mental Health Services Administration's national helpline 1-800-662-HELP (4357)
Any type of crisis	Text HOME to 741741  from anywhere in the USA
Thoughts of hurting or killing yourself Thoughts of hurting your baby or anyone else	National Suicide Prevention Lifeline 1-800-273-TALK (8255) 911

If you have questions about your rights as a study participant, you may call the NORC office in charge of protecting your rights, toll-free, at 1-866-309-0542, the LTG Associates’ Project Director at 301-270-0882, or the OWH Project Manager at (202) 690.0348.