1. Focus Group Brief Survey
Participant ID: _____
Focus Group Discussion Questionnaire
1. How would you describe your general health?
a. Poor
b. Fair
c. Good
d. Very good
e. Excellent
2. How often is having enough food for your family a concern?
Never
Occasionally (i.e. 1-2 times per month)
Sometimes (3-4 time per month)
Often (at least 1 time per week)
Daily (every or nearly every day)
3. Are you concerned about having poor eating habits? Yes No
4. Are you concerned about your children being…
Overweight? Yes No
Underweight? Yes No
5. Are you concerned about your children having poor eating habits? Yes No
6. Are you concerned about being…
Overweight? Yes No
Underweight? Yes No
7. Have you ever been on a diet to lose weight?
a. No
b. Yes If yes, were you successful in meeting your weight loss goals? _____
Why or why not? ________________________________________
2. Focus Group Brief Survey
Participant ID: _____
8. Height: __________
9. Weight: __________
10. Age: __________
11. Are/did you breastfeeding your new baby? YES NO
12. How long are you planning to/did you breastfeed?
a. I never breastfed
b. Less than 2 weeks
c. 2 weeks – 1 month
d. 1 to 3 months
e. 3 to 6 months
f. 6 to 12 months
g. More than one year
13. What is the best way for you to receive information about improving your health?
Rank the following from 1-5, with 5 being the being the best.
Text message _____
Email _____
Workshop (in-person) _____
Phone call _____
Handout _____
Other _____________________
14.If you were to receive a text message about health information, what would be the
best time of day to receive it?
a. 6 a.m.-9:30 a.m. (early morning)
b. 10 a.m.-11:30 a.m. (mid-morning)
c. 12:00 p.m.-1:30 p.m. (lunch hour)
d. 2:00 p.m.-4:30 (afternoon)
e. 5:00 p.m. or later (evening)
15.How often would you like to receive a text message? (Example: daily, once a week,
once a month) ____________________________
3. Focus Group Brief Survey
Participant ID: _____
16.If you were to receive an email or about health information, what would be the best
time of day to receive it?
a. 6 a.m.-9:30 a.m. (early morning)
b. 10 a.m.-11:30 a.m. (mid-morning)
c. 12:00 p.m.-1:30 p.m. (lunch hour)
d. 2:00 p.m.-4:30 (afternoon)
e. 5:00 p.m. or later (evening)
17.How often would you like to receive an email? (Example: daily, once a week, once a
month) ____________________________
18.How likely is it that you would get together in a group with other young women to
discuss topics related to health, weight, etc?
Not at all
likely
Not very
likely
Somewhat
likely
Fairly likely Very likely
19.If workshops were offered, would you prefer…
Weekdays (Monday, Tuesday, Wednesday, Thursday, Friday) _____
OR
Weekends (Saturday, Sunday) _____
Morning (8 a.m.-11:30 a.m.) _____
Afternoon (12 p.m.-4:00 p.m.) _____
Evening (4:30 p.m.-6:30 p.m. _____
20.Which of the following would increase your chances of participating in offered
workshops? “I would come if….” (Check all that apply below)
Free childcare was offered during the workshops ______
The workshop was being offered at a nearby location ______
Light snacks or dinner was offered at the workshop ______
Transportation was offered to the workshops ______
21.How long do you think a session should be? (Example: 30 minutes, 1 hour)
____________
4. Focus Group Brief Survey
Participant ID: _____
22.How often do you think sessions should occur? (Example: once a week, once a
month) _____________________________
23.If you were to receive a phone call about health information, what would be the best
time of day to receive it?
a. 6 a.m.-9:30 a.m. (early morning)
b. 10 a.m.-11:30 a.m. (mid-morning)
c. 12:00 p.m.-1:30 p.m. (lunch hour)
d. 2:00 p.m.-4:30 (afternoon)
e. 5:00 p.m. or later (evening)
24.How often would you like to receive a phone call? (Example: once a week, once a
month) ____________________________
25.Are there any health topics that you would like to know more about at this time?
___________________________________________________________________
26.Do you own a cell phone? (If your answer is no, you are finished with the survey)
a. No
b. Yes
27.What cell phone company do you use?
a. AT&T
b. Boost Mobile
c. Sprint
d. T Mobile
e. Verizon
f. Other (please specify) ___________________________________________
28.How many minutes are included in your monthly cell phone plan?
a. Less than 100
b. 100-300
c. 300-500
d. More than 500
e. Other (please specify) ___________________________________________
5. Focus Group Brief Survey
Participant ID: _____
29.How often do you use your cell phone?
a. Less than 1 time per week
b. 3-5 times per week
c. Daily
d. 1-3 times per day
e. More than 3 times per day
30.Does your plan include text messaging? (If your answer is no, go to question 39)
a. No
b. Yes
31.How many texts are included in your monthly cell phone plan?
a. None
b. 500
c. 1000
d. Unlimited
32.Do you use text messaging?
a. No
b. Yes If yes, how often? _______________________________________
33.Do you consider yourself to be: (circle all that apply)
a. African-American/Black
b. Caucasian/White
c. Native American
d. Asian or Pacific Islander
e. Hispanic
f. Other (please specify) ______________________
34.What is your marital status?
a. Never married
b. Currently married
c. Separated
d. Divorced
e. Widowed
6. Focus Group Brief Survey
Participant ID: _____
35.What is the highest level of school or the highest degree you have received?
a. Less than high school
b. High school graduate or GED
c. Some college
d. Associates degree
e. Bachelors degree
f. Graduate degree
36.Employment:
a. Employed part-time
b. Employed full-time
c. Unemployed/looking for a job
d. Student
e. Other (please specify) _________________
37.What is your total yearly household income (before taxes)? (circle one letter)
a. Under $10,000
b. $10,000-$19,999
c. $20,000-$29,999
d. $30,000-$49,000
e. $50,000-$59,999
f. $60,000 or above
38.How many children do you have? ___________________
39.What is the age of your youngest child? _______________
40.We’re going to be conducting some other studies with post-partum moms living here
in East St. Louis. Would you be interested in being contacted for future projects?
a. No
b. Yes If yes, please provide your name, phone number and email address on
the last page of this survey.
Thank you for taking the time to complete this survey.
