INFLUENZA AND PNEUMOCOCCAL IMMUNIZATION:
A QUALITATIVE ASSESSMENT OF THE BELIEFS OF PHYSICIANS AND OLDER HISPANIC AMERICANS AND AFRICAN AMERICANS
Final Report

Office of Health Communications
National Immunization Program
Centers for Disease Control and Prevention
May 2003

I. INTRODUCTION
A. Purpose
The National Immunization Program (NIP) at the Centers for Disease Control and Prevention (C.D.C.) commissioned a series of consumer focus groups and physician interviews to collect qualitative data about beliefs, behaviors, and barriers that cause low influenza and pneumococcal immunization rates among older African-American and Hispanic-American populations. 

The purpose of the research was to
•	Identify knowledge, beliefs, and behaviors among Hispanic-American and African-American populations age 65 years and older related to influenza and pneumococcal immunization. 
•	Increase understanding of physicians’ attitudes and behaviors as they relate to influenza and pneumococcal immunization.
•	Extend earlier efforts to identify barriers and facilitators related to influenza and pneumococcal immunization. 
•	Assess the understanding, appeal, and potential impact of influenza immunization messages and materials on physicians and on older Hispanic Americans and African Americans. 
•	Assess knowledge among older minority audiences about pneumonia and the pneumococcal polysaccharide vaccine.

B. Methodology
All data for this project were collected during the period August 20–27, 2002. All research participants—physicians and consumers—were recruited by the focus group facilities in the cities where the focus groups were held. These facilities used a preexisting database of prospects to contact people for the study. Prospects initially were contacted by phone. Those who agreed to participate received written confirmation about the study and detailed directions for getting to the facility. To ensure a high level of participation, focus group participants and the physicians who were interviewed received stipends.
1. Consumer Focus Groups 

Eighteen focus groups were held in five cities: Chicago, Illinois; Jackson, Mississippi; Milwaukee, Wisconsin; Rochester, New York; and San Antonio, Texas. Eight of the groups were made up of Hispanic Americans and ten were made up of African Americans. All participants were 65 years of age or older. 

During the recruitment process, people were assigned to groups as one of the following:
•	Doers: People who are very likely or somewhat likely to get a flu shot this season.
•	Nondoers: People who are somewhat or very unlikely to get a flu shot this season. 

Each focus group included only persons of the same race, the same gender, and the same doer/nondoer status. 

To ensure varying levels of socioeconomic status, respondents were asked whether their annual household income fell above or below the national median for their race—$33,000 per year for Hispanic Americans and $30,000 per year for African Americans. Groups were recruited so that roughly half the members of each focus group fell above and half below the median income levels.

People were excluded from the study if they had any of the following characteristics:
•	They or a member of their immediate family work in the fields of advertising, public relations, or market research.
•	They or a member of their immediate family are a physician or a nurse.
•	They are allergic to the flu shot or have some other medical reason for not getting a flu shot.
•	They participated in another focus group or some other type of market research within the past six months.
•	They said they were “not sure” whether they would get a flu shot this season. 
•	They indicated that they watched or listened to less than five hours of television or radio each week. 

The table below provides more detail about the composition of the focus groups completed during this study.

TABLE: Number of Focus Groups: Overview  
Key: (D=doer; ND=nondoer)

San Antonio, Texas
Hispanic-American Seniors, Male= doer and nondoer   Female=doer and nondoer   
African-American Seniors, none 

Chicago, Illinois
Hispanic-American Seniors, Male= doer and nondoer   Female=doer and nondoer   
African-American Seniors, Male=nondoer   Female=nondoer 

Rochester, New York
Hispanic-American Seniors, Male= none    Female=none  
African-American Seniors, Male=nondoer   Female=nondoer 

Milwaukee, Wisconsin
Hispanic-American Seniors, Male= none    Female=none  
African-American Seniors, Male=nondoer   Female=nondoer 

Jackson, Mississippi
Hispanic-American Seniors, Male= none    Female=none  
African-American Seniors, Male=doer and nondoer   Female=doer and nondoer 

Total number of focus groups=18
END OF CHART

Among Hispanic Americans, the Chicago groups included a greater diversity of countries of origin, with many participants born outside the United States. In San Antonio, almost everyone was born and raised in Texas, albeit in a Spanish-language setting.

Professional facilitators used a standardized moderator’s guide containing a detailed series of questions. This ensured that all participants in each group were asked the same questions in roughly the same manner and allows comparison of patterns and trends across focus groups. All focus groups involving Hispanic Americans were conducted in Spanish, with each session simultaneously translated for the benefit of the people observing the groups.

Copies of the moderators’ guides used for these consumer focus groups can be found in Appendix C at the end of this document. 

2. Physician Interviews
Physicians were recruited by the focus group facilities in each of the five cities for one-on-one interviews. Physicians identified themselves as practicing in the following specialties: family medicine, internal medicine, cardiology, and pulmonary medicine.  Each participating physician reported regularly treating older African Americans and Hispanic Americans. Among physicians in family medicine and internal medicine, at least one-third of their current patients are either Hispanic American or African American, and at least one-third of their patient base is 65 or older. These standards were not applied to physicians in cardiology or pulmonary medicine because their practices are based on referrals from primary care physicians (PCPs). The physicians in this study represent a variety of races and age groups. For detailed information about the screening criteria for physicians who participated in this study, see Appendix B. 

The table below shows the breakdown by medical specialty of the physicians who participated in this study. As with the consumer focus groups, a professional interviewer used a standardized series of structured questions to elicit opinions and information from each physician. Each interview was scheduled to last one hour. A copy of the moderator’s guide used for the physician interviews can be found in Appendix D. 

CHART
Physician Interviews
Number of Physicians, by Specialty

Chicago, Illinois
1 Cardiology
1 Family Medicine
1 Internal Medicine
1 Pulmonary Medicine
Jackson, Mississippi
1 Family Medicine
2 Internal Medicine
1 Pulmonary Medicine
Milwaukee, Wisconsin
1 Cardiology
1 Family Medicine
1 Internal Medicine
1 Pulmonary Medicine
Rochester, New York
1 Internal Medicine
San Antonio, Texas
1 Cardiology
1 Family Medicine
1 Internal Medicine
1 Pulmonary Medicine

Qualitative Research
•	Qualitative research is designed to develop insight and depth of understanding, rather than quantitative estimates. 
•	Qualitative research is designed to obtain in-depth responses about what people know, think, and feel. 
•	The value of qualitative research is its ability to collect unfiltered comments from representatives of target populations. 
•	A qualitative sample must be large enough to ensure that most or all important perceptions are elicited and recorded.  

II. KEY FINDINGS

A. Consumers/General:  Flu 

1. Knowledge, Beliefs, and Behaviors 
a. Consumer focus groups revealed the following key findings about participants' general knowledge of flu and pneumonia and related immunization vaccines. Across the groups, consumers:
(1) Were knowledgeable about flu and the flu shot;
(2) Recognized that flu is caused by a virus that is spread through contact with other humans (for example,inhaling germs transmitted by sneezing or coughing, shaking hands, or having close physical contact);
(3) Associated colds and flu with fall and winter seasons;
(4) Associated colds and flu with cold weather (for example, lower temperatures cause people to become susceptible to illness, people “get chilled,” “don’t wear enough clothes,” or are “exposed to the elements”);
(5) Associated flu with aching muscles, runny nose, headache, stomach upset, body aches, and loss of appetite;
(6) Were often unable to distinguish between flu and a cold—some suggesting that duration or severity of symptoms distinguished the two;
(7) Often thought that there was a continuum of disease progression from cold to flu to pneumonia;
(8) Perceived that pneumonia is very dangerous and can cause death;
(9) Were mostly unaware of the pneumonia vaccine (“Why didn’t my doctor tell me about it” was a typical comment); and
(10) Did not think the pneumonia vaccine would cause pneumonia.
 
b. Strategies regarded as useful in avoiding flu were:
(1)	Washing hands;
(2)	Taking vitamins;
(3)	Dressing warmly in cold weather;
(4)	Not getting wet or chilled
(5)	Eating healthily;
(6)	Getting enough rest and not getting run-down; and
(7)	Getting a flu shot. (It is noteworthy that only a few people listed this as a strategy for avoiding flu and that no one listed it as a first strategy.) 

c. Doers' reasons for getting a flu shot:
(1)	They had previously had the flu and did not want to repeat the experience;
(2)	Another person (doctor, friend, or family member) convinced them to have the shot (“gave me no choice.”); and/or
(3)	They had other health problems and realized that they were at high risk for complications from flu. 

	d. Nondoers' reasons for NOT getting a flu shot: 
(1)	Believed overall that “if you get the shot, you get the flu”;
(2)	Believed that they had become ill from having a flu shot;
(3)	Knew someone who had gotten sick (or thought they had gotten sick) from a flu shot;
(4)	Believed themselves to be healthy and did not want to chance getting sick from the shot;
(5)	Believed they could control in large part whether or not they get the flu (that is, they could reduce or eliminate the likelihood of getting the flu without getting a flu shot); and
(6)	Believed that flu shots were for “older people” or for people who are relatively sick or weak. 

2. Preferred Sources of Information  
Consumers across the groups concurred that they prefer to get their health information from the following sources: 
a.	Health institutions and health professionals (most cited sources, but men were less likely than women to want to accept their physician’s advice); 
b.	Physicians, newspapers, senior centers, government health centers, coworkers, pharmacies and supermarkets, religions organizations, friends, and insurance reminders;
c.	Media, with radio and television being the preferred media; and
d.	Experiences of friends who claimed to have gotten flu from the flu shot (for some, this source carried more weight than medical advice from physicians).
 
Some African-American participants articulated distrust of the government, physicians, and drug companies. This sentiment was strongest among nondoers and mentioned less often and with less negativity than in research carried out in 2000. Hispanic-American participants did not allude to this.

Across the groups, participants noted that they trusted as spokespersons: 	
•	A physician or other health professional;
•	Wives;
•	Family members; and 
•	Peers (people like them).
Celebrities and politicians were considered less influential. 

3. Key Conclusions
a.	Knowledge about flu and the flu shot neither correlates with nor predicts whether people will get the flu shot. 
b.	Doers are driven by personal experience:
(1)	Having previously had the flu;
(2)	Trust in physicians; 
(3)	Openness to persuasion from a family member;
(4)	Having another health condition that puts one at risk; and
(5)	Strong understanding of the age effect—that older people are more at risk of complications. 
c.	Nondoers reported that they do not get the shot because they believe the shot causes the flu and they believe they can control their health (strong internal locus of control).
d.	Factors that differentiate doers from nondoers include the following: 
(1)	Past experience of having had the flu. Doers definitely had experienced the flu.
(2)	Understanding (admitting) that health risks increase with age, regardless of other factors.
(3)	Perception that getting the flu can be controlled by using methods other than the flu shot. Doers had a more external locus of control than nondoers. 

4. Comments and Recommendations 
a.	The concept of protecting others by getting the flu shot (especially visuals showing family members) resonated well with all groups.
b.	There is a group of adamant decliners who will not get a flu shot no matter what, indicating that resources may best be focused on those who are more likely to change. 
c.	Materials and messages should use emotional appeals, such as protecting your family, as well as provide information and facts about flu and pneumonia. 
d.	Use few words, limited body copy, and BIG print. 
e.	Prominently place C.D.C.’s name and logo, because it is recognized and respected. 
f.	Promote the fact that current influenza vaccines are more highly purified and less likely to cause local or systemic reactions than vaccines used before the mid-1960s. Some people may not know this; some who were vaccinated many years ago may have experienced a systemic reaction to the less purified flu shot. 
g.	Address misconceptions in messages promoting the current vaccine; for example, stress that the current vaccine is “new and improved” or that “technology is more advanced now” than it was in the mid-1960s.
 
B. Consumers: Hispanic Americans  

The following key findings emerged from focus groups with older Hispanic Americans.
1. Messages
a.	Participants interpreted the fight the flu slogan correctly. However, nondoers did not believe that the flu shot prevents flu; therefore, they perceived the message as completely false and distrusted the ad.
b.	Participants reported that the message 20,000 deaths was more eye-catching and motivating than the message 114,000 hospitalized. (“We’re all trying to escape death.”)
c.	 Get a flu shot to protect your family was a salient message for most participants.
d.	Visuals containing photos of family members (for example, grandfather with baby) or multigenerational families resonated on an emotional level. (“I want to see my grandchildren grow up.”)
e.	Nondoers were not swayed even by this visual appeal.
f.	The Spanish word for flu differs depending on country of origin and possibly length of time in the United States.  In Chicago, participants used the words “la gripe."  In San Antonio, participants used “la flu” or "la influenza.”

2.	Promotional Items
a.	Magnetic picture frames were the preferred items. (“We could see it every day on the fridge.”)
b.	Jar openers were of interest.
c.	Letter openers, squeeze balls, and magnifying glasses were of less interest.

C. Consumers: African Americans

1.	Messages
a.	Twenty-thousand deaths is a credible and specific message that implies urgency.
b.	The idea of getting a flu shot to protect a loved one appeared to be motivating to this group. 

      2. Materials 
a.	Images that resonated most were of people like the participants—their peers—with whom they could personally identify and health care professionals.
b.	Visuals using an older African American generated attention and made participants realize that they were the target audience for the message.
c.	Men were particularly drawn to the image of the grandfather with his grandchild.
d.	The groups liked the portrayal of the grandfather as the protector of the family.
e.	Ethnicity of the person in the photos needs to be very clear.
f.	Images need to be sharp, not faded or blurry.
g.	Facial expressions—eyes, a smile, and a healthy look—all drew participants’ interest and comments. 
h.	African-American participants seemed to think the female provider pictured was a nurse; they said she did not have all the right “tools.” This may be a reflection of the stereotype that a physician is male; it also points up the importance of selecting photographs of physicians with items a doctor would have. 

3. Promotional Items
The reactions of African-American participants to the promotional items were similar to those of the Hispanic-American groups:  
a.	Magnetic picture frames were the preferred items.
b.	Jar openers were also of interest.
c.	Letter openers, squeeze balls, or magnifying glasses were of less interest. 

D. Physicians 

1.	Knowledge, Beliefs, and Practices
a.	Both influenza and pneumococcal immunizations are important.
b.	Physicians expressed widespread support for and interest in both the flu shot and the pneumococcal polysaccharide vaccine. They have up-to-date information about both immunizations.
c.	Specialists tended to know less about vaccinations and about morbidity and mortality associated with influenza.
d.	Because time with patients is limited, physicians said they couldn’t engage in long conversations to persuade a single patient to get the flu shot. 
e.	Most of those interviewed indicated that race, ethnicity, or gender are not factors that distinguish those who get flu shots from those who do not.
f.	Participants believed that regular access/exposure to the health care system is the most consistent predictor for who will get a flu shot. 
g.	Most believed that most patients who request a flu shot have had the flu in   the past. 

2.	Cost of the Flu Shot: Physician Perceptions
a.	Most physicians, particularly those who are employees of health systems or  specialists, had no knowledge of what their offices charge for a flu shot. 
b.	Most said reimbursement rates were not a significant part of the decision-making process.
c.	Physicians in smaller practices (three or fewer) were more likely to know about the cost of flu shots and the profit-or-loss margin. 
d.	When cost margin was known, the flu shot was seen as a patient service or a matter of ethics and good clinical care, not as a revenue generator. 
e.	Some physicians recommended that promotions should target other clinical staff, such as nurses and clinic managers. 
f.	Opinion on financial incentives for physicians was mixed—some believed it to be a good idea, while others considered it unethical.

3.	Use of Standing Orders and Reminder/Recall Systems
a.	Many primary care physicians reported using standing orders.
b.	Doctors often used informal methods to remind themselves to offer vaccinations or to track these vaccinations. 

4.	Recommendations
a.	Physicians asked to receive materials that are short and to the point, and that carry a scientific message.
b.	C.D.C.'s logo should be prominently displayed on the material. C.D.C. is well respected by physicians, and C.D.C.’s name and logo would cause them to attend to the materials. 
c.	Promotional items were of no interest.
d.	Physicians reported that their preferred channels of communication include:
(1)	Written communication from hospitals where the physicians have privileges;
(2)	Medical journals; and
(3)	Information provided to practice administrators or managers.
(4)  Information delivered by mail was of less interest because of the high volume of mail physicians receive.
 
 III. DETAILED FINDINGS
 
A. Consumers

One goal of this project was to determine whether Hispanic Americans and African Americans have different levels of knowledge about flu and pneumonia. In addition, the study was crafted to test whether there are differences in knowledge, beliefs, and opinions in different areas of the country. Responses to all aspects of this project—information about the flu, and reactions to the ads and promotional materials—were strikingly similar and showed almost no differences in ideas and opinions between Hispanic Americans and African Americans. Geographic region rarely played a meaningful role in influencing patterns of responses. The few distinctions that did emerge are noted in the body of this report.

As mentioned in the project goals, data presented in this section of the report will be compared with data collected in October 2000 from a comparable population using comparable methodology. This previous study will be referred to as “the 2000 study.”

1. Flu Knowledge, Beliefs, and Behaviors  

a. What is the flu? How do people contract the flu?
People in all focus groups said that flu is “a virus” that is spread through contact with other humans; for example, by inhaling germs transmitted by sneezing or coughing, shaking hands, or other close physical contact. In the 2000 study, many respondents, particularly Hispanic Americans, were less aware that flu is a virus. Many people described flu as “an untreated cold,” an opinion that was expressed in the current study but not by as many respondents.

b. What illnesses do you associate with fall and winter months?
Cold and flu were the most frequent responses in each group. Some people speculated that flu could turn into pneumonia. Others said they have had sinus problems or allergies during those seasons of the year.

In each focus group, respondents indicated that people are susceptible to flu in the fall and winter months because temperatures are lower and people are more at risk when they “get chilled,” “don’t wear enough clothes,” or are “exposed to the elements.”  In the 2000 study, respondents offered precisely the same shopping list of illnesses.

c. What are the symptoms of flu?
Again, focus group participants were almost unanimous in listing the symptoms they associate with flu:
(1)	Aching muscles;
(2)	Runny nose;
(3)	Headache;
(4)	Stomach upset;
(5)	Body aches; and
(6)	Loss of appetite.

Many focus group participants were confused when the moderators asked them to distinguish flu from a bad cold. Some people said that duration of symptoms (a cold lasts a week to 10 days, while the flu can last much longer), symptom severity, or a high fever might distinguish the two illnesses. People generally said they believe that flu is more debilitating than a cold. Responses about the symptoms of flu and the inability to distinguish a cold from flu were almost identical with those gleaned during the 2000 study.

d. Is flu a serious illness?
Most people indicated that they understood flu to be a serious illness, although the actions of nondoers suggest that this awareness often has little impact on subsequent behavior. Respondents affirmed that flu can cause death, although they thought the people most at risk are people different from them—older people; people with other serious, chronic illnesses; or those with compromised immune systems. In the 2000 study, respondents identified persons with “weaker immune systems” as those most at risk. 

Once they get the flu, participants reported that they take over-the-counter cold and flu medicines for symptomatic relief, plus homeopathic and other remedies such as herbal teas or tequila with lemon. They also suggested that people with flu should not drink cold liquids. In the 2000 study, people mentioned using herbal teas, particularly those that contain echinacea, as a preventive measure and a way to deal with flu symptoms.

Most people, and particularly nondoers, said they do not go to the doctor unless they feel extremely ill. In this group, most suggested that the best approach is to “tough it out” at home.

e. How can you avoid contracting the flu?
Most people said that avoiding contact with other people is the best way to avoid flu. Recognizing that this is impractical, they proposed other measures:
(1)	Regular hand-washing with soap;
(2)	Taking vitamins daily;
(3)	Dressing warmly in cold weather;
(4)	Not getting wet or chilled when outside in cold weather;
(5)	Eating healthy—plenty of fruits and vegetables; and 
(6)	Getting enough rest and not getting “run-down.”

Some people recommended a nontraditional or homeopathic prophylaxis such as taking herbs daily or taking castor oil every three months to “clean out your system.”  In some focus groups, people spontaneously mentioned getting a flu shot as a way to avoid getting the flu. In other groups, the shot was not mentioned. When analyzing the groups that suggested the flu shot, there was no discernible pattern based on ethnicity, gender, or region of the country.

These responses closely track those in the 2000 study, where respondents mentioned Vitamin C, hand-washing, dressing appropriately for the weather, and avoiding contagious people. The most striking difference was that African-American respondents in 2000 were much more likely to mention “maintaining a strong spiritual connection” as a key to avoiding the flu and to good physical health in general. In 2000, the flu shot was cited as well as a method for avoiding flu or minimizing its impact.

f. What have you heard about the flu shot?
Almost all respondents had heard about the flu shot. The most frequent comment among nondoers, by a large margin, was, “If you get the flu shot, you get the flu.” Most of these respondents got information about the flu shot from family members, friends, and personal experience. The idea that the flu shot causes flu also was a prevalent theme in the 2000 study.

People with positive views about the flu shot believe that the shot is necessary and beneficial. Their information comes primarily from trusted physicians, family members, and past positive experience with the flu shot. Several people who said they value the flu shot also said they have had flu in the past and “don’t ever want to be that sick again.”
 
g. Do you plan to get a flu shot this season?  Why or why not?
Doers said they get the shot because:
(1)	They have had the flu in the past and do not want to repeat the experience;
(2)	Someone—their doctor, a friend, a family member—convinced them (or 	“gave me no choice”); and
(3)	They have health problems and realize that they are at risk.

Doers convinced about the effectiveness of the shot suggested that even if they got the flu it would be a milder case and they would avoid possible complications, such as bronchitis or pneumonia. They believe that their immune systems are not as strong as when they were younger and that by getting the flu shot they will protect others, especially family, as well as themselves.

Nondoers said they don’t get the shot because: 
(1)	They got sick from the shot in the past.
(2)	They know someone who got sick from the shot.
(3)	They feel healthy (“I never get the flu”). 
(4)	They perceive an internal locus of control—that they can personally control whether they will contract the flu and that they can take steps to reduce or eliminate the likelihood of getting the flu without getting the flu shot.
(5)	They assume that the shot is for people older or sicker than they are, although some members of these focus groups have diabetes or other serious medical conditions.
(6)	They use other means to stay healthy—getting exercise, taking Vitamin C.
(7)	They don’t like/are afraid of shots and needles.

Nearly all nondoers who claimed that they contracted flu after having a flu shot had not been diagnosed by a physician as having the flu. Almost always, their conclusions were drawn from self-diagnosis.

Attitudes among nondoers were very similar regardless of gender, ethnicity, or geographic location. Their basic and pervasive belief was that the flu shot causes flu. Among Hispanic Americans, males in San Antonio took their rationalization one step further, asserting that women and “people who take too much medicine” are the ones who get the shot. Also, although most respondents were aware that the shot is often available free of charge, several Hispanic Americans in Chicago asked about the price of the immunization.

In the 2000 study, many similar patterns emerged. In that research, people also used the phrase “if it ain’t broke, don’t fix it” to describe their reluctance to get the shot. As in the current study, some respondents agreed that having other risk factors would dictate getting a flu shot; but they followed up by saying that this “doesn’t apply to me.”  Hispanic Americans in the 2000 study were more likely to say that the flu shot was not valued because getting a flu shot is not a custom in their country of origin (mainly Mexico).

h. Where do you go to get information about the flu shot?
Information regarding the flu shot is obtained from:
(1)	Physician (during an office visit or, less personally, through a reminder card or call from office staff);
(2)	T.V. ads/newspapers, television, and radio. 
(3)	A.A.R.P./senior centers;
(4)	Government health centers;
(5)	Coworkers;
(6)	Pharmacies/supermarkets;
(7)	Religious organizations/faith community;
(8)	Friends; and
(9)	Insurance reminders.

Focus group participants reported that health professionals and health institutions are the most credible sources of information about flu shots. They also said that health care professionals are more knowledgeable about this topic than their friends or other laymen. However, some were more likely to believe friends claiming to have contracted the flu after getting a flu shot than their physicians claiming that flu shots do not cause the flu. Some respondents, particularly men, said they were less likely to accept their physicians’ advice about getting a flu shot. These respondents said they rely most heavily on their own counsel.

A subset of respondents suggested that a patient’s health is not always the physician’s first concern when recommending a flu shot. This group believed that some physicians recommend flu shots to increase their income. African-American male respondents tended to hold this view of doctors much more than participants in other groups. Hispanic Americans of both genders were unlikely to have such negative opinions 
about physicians.

Wives appear to play a big part in convincing their husbands to get a flu shot; most male African-American respondents reported trusting their wives’ opinions on what they should do about their health.

Participants in the 2000 study said that information from a trusted physician was by far the most reliable source of facts, although the media was a secondary source of data. 

Two major issues were articulated in 2000 that were not prominent in the current study:
•	First, people in 2000 were very forthright in saying they were fearful of needles or scared to get a flu shot. Respondents alluded to this factor only indirectly in the current study. 
•	Second, a much stronger “antigovernment” sentiment was expressed in the 2000 study. Many respondents in that study, particularly African Americans, made explicit reference to the Tuskegee incident in justifying their distrust.

i. Who is the best spokesperson to tell you about the flu shot this year?
Participants in these focus groups defined "spokesperson" as an individual who would be well suited to persuade members of the general public to get a flu shot this year. This study was not designed to identify the types of individuals who might be effective in raising the public’s general awareness about flu or the flu shot.

Most respondents said that a physician or other health professional would be the best spokesperson. Some said they want to hear from family members. Any spokesperson would be more credible and trustworthy if that spokesperson had had a flu shot. 

In the San Antonio female doer group, women recommended that the evening soap operas (“which everyone watches”) show a dramatic episode involving people getting flu shots. One woman also recommended that Katie Couric or another news anchorperson help get out the word on the flu shot.

Respondents had negative impressions about government officials, entertainers, or celebrities serving as spokespeople. A representative comment was “What do they know about the flu?”  For various reasons, they questioned the motives of people in these groups. Most respondents prefer a spokesperson to have the following attributes:
•	Personal experience with flu shots;
•	Knowledge of the latest medical information; and
•	Concern about people.

Summary Comments
In general, attitudes related to flu and flu shots were very similar among groups, with ethnicity, gender, and geography having little or no impact on response patterns. The only subtle difference was that, unlike African-American respondents, Hispanic Americans never expressed or alluded to any fear or distrust of institutions, physicians, health care employees, or drug companies.

The major differences were seen between doers and nondoers. Most of the nondoers said they had had a flu-like reaction to the shot themselves or knew someone who claimed to have had such a reaction in the past. None of these people realized that the vaccine had been changed from a live virus to a dead virus years ago. Because these people are over 65 years old, they may well have had a reaction to the live virus years earlier.

Participants suggested a number of approaches to creating an effective message:  
•	Inform nondoers at a grassroots level about the change in the vaccine and state clearly that the flu shot no longer can cause these symptoms. 
•	Use the message “Technology is more advanced now than when I got the shot the first time” and/or “The doctor told me it’s a dead virus now, so I gave it another chance."  This recommendation shifted the attitudes of two respondents from nondoer to doer. 
•	The personal experience of a health worker could be persuasive.
•	Make sure everyone knows that they can get a flu shot free. Although many people know this, perceived cost is a possible barrier for some nondoers.

The following table shows the similarities and differences in knowledge and attitudes between doers and nondoers.

Possible Determinants
Do you know how the flu is transmitted? 
Doers: Yes     
Nondoers: Yes

Do you know the difference between a bad cold and the flu? 
Doers: Yes
Nondoers: Yes

Are you afraid of needles?  
Doers: No     
Nondoers: Varies Among Respondents

Do you believe the flu shot is only for other people? 
Doers: No     
Nondoers: Yes

Do you believe the benefits of getting the flu shot outweigh any possible negative outcomes?  
Doers: Yes     
Nondoers: No

Do you trust your doctor? 
Doers: Yes     
Nondoers: Data Inconclusive

Do you think you can control whether you get the flu by using methods other than the flu shot (internal locus of control)? 
Doers: No  
Nondoers: Yes

Have you ever had the flu? 
Doers: Yes     
Nondoers: Varies Among Respondents

Do you know that your health risks (the problems you can have if you get the flu) increase with age? 
Doers: Yes   
Nondoers: Varies Among Respondents

Have you ever gotten a flu shot?  Do you have personal experience with flu shots? 
Doers:  Yes   
Nondoers: Yes

Have you heard stories from other people who have gotten flu shots? 
Doers: Yes    
Nondoers: Yes

This pattern of responses suggests that local health officials and other professionals can use their time and resources effectively by focusing on the following themes:
•	Only the flu shot can prevent flu or minimize its impact. No other measures are effective.
•	The flu shot is for everyone age 65 or older.
•	The shot is not painful.
•	C.D.C., a trusted, nonpartisan organization, recommends the flu shot for people like them (people age 65 or older).

2. Pneumonia Knowledge, Beliefs, and Behaviors
Participants perceived pneumonia to be very dangerous. Everyone was aware that it can result in death. However, most respondents were unaware that the pneumococcal polysaccharide vaccine exists. “Why didn’t my doctor tell me about it?” was the typical reaction when moderators probed this issue in the focus groups. 

Some respondents had very specific information about the pneumococcal polysaccharide vaccine. Several people knew that the shot is given only every 5 to 10 years, not annually. A few people believed that the vaccine could protect against the flu. Some of the people who were unfamiliar with the pneumococcal polysaccharide vaccine wanted more information about its potential side effects.

Almost no one believed that if you get the pneumococcal polysaccharide vaccine, you get pneumonia. This may suggest that nondoers could be introduced positively to the immunization process through the pneumococcal polysaccharide vaccine, then later persuaded to get an annual flu shot.

Overall, pneumonia and the pneumococcal polysaccharide vaccine present a much “cleaner” picture than the flu shot. Participants expressed no misconceptions about side effects or about the shot giving the recipient the illness. 

In the 2000 study, support for the pneumococcal polysaccharide vaccine was much less consistent. In this earlier research, people were much more likely to use the same excuses they used in justifying their refusal to get a flu shot: that they were healthy and did not need the shot, and that they were not likely to get pneumonia.

3. Materials Tested
In all focus groups, participants were asked to react to proposed posters/print ads and various promotional items. The creative work presented to African Americans was totally different from that presented to Hispanic Americans. In addition to differences in concept approach, text was presented to Hispanic Americans in Spanish. 

a.	Flu shot information presented to Hispanic-Americans 
(1)	Item:  Fight the Flu. This phrase was interpreted correctly in the context of all the ads—that the fight is a preventive measure. However, nondoers did not believe that a flu shot fights the flu. They believed that this message is totally false, which led them to distrust or dismiss other elements in the ad.  
(2)	Item:  20,000 Deaths. The number 20,000 attracted people’s attention. Most were shocked, but some of the nondoers continued their rationalization process by saying, “That’s not a very big number, given the millions in the U.S.” or “If I get the shot and get the flu, I can die, too.”   

Visual 
Key Strengths
•	Easy to see
•	Easy to read (large type)
Key Weaknesses
•	Cluttered (smaller type)
•	No pictures or images to draw people into the ad

Message
Key Strengths
•	New information—most respondents were unaware of the high number of deaths
•	20,000 deaths was compelling, frightening
Key Weaknesses
•	Too many words
•	20,000 should be part of the headline
•	May not persuade people to get the flu shot

(3)	Item:  114,000 Hospitalized. For respondents, this fact paled in comparison with the 20,000 deaths. All thought that the 20,000 number was more effective in getting people’s attention. “We’re all trying to escape death.”  

Visual
Key Strengths
•	Easy to see
•	Easy to read (large type)
Key Weaknesses
•	Cluttered (smaller type)
•	No pictures or images to draw people into the ad

Message
Key Strength
•	Clear message—easily understood
Key Weaknesses
•	Hospitalization has little impact, especially compared with death
•	Not persuasive in getting people to get a flu shot

(4)	Concept:  Manuel Ramírez. Some regional differences were noted. Respondents liked Manuel, who “looks healthy to me."  “We all think we’re healthy like Manuel, but we could become part of the 20,000.” Respondents in Chicago seemed to identify more with Manuel, while a few in San Antonio thought he looked like a ranch hand, who “seems older than 66.”  In San Antonio, male nondoers asserted that “ranchers like Manuel never get sick.” In general, people thought that this ad did not give the 20,000 deaths the emphasis they deserve.

Visual
Key Strengths
•	Looked strong and healthy
•	Attractive colors and layout
•	Tag line in red and black stands out
Key Weaknesses
•	Too wordy
•	Not everyone identifies with the farm worker image

Message
Key Strength
•	“Even healthy people can get the flu”
Key Weakness
•	The headline does not contain information on flu. This is vital, since most people will read only the large print.

(5)	Concept:  So you think… This ad was among the least preferred, based on the photo and the wording.   

Visual
Key Strength
•	Strong-willed woman
Key Weaknesses
•	Supercilious expression
•	Spokesperson looks too young to be 65, yet is not identifiable as an “expert”
Message
Key Strength
•	Tag line in red and black
Key Weaknesses
•	So you think… phrase is negative
•	Copy is long and confusing

(6)	Concept:  Provider, Protector. The family appeal was easily understood and conveyed the message of “protecting others."  Group members would like to see an “older-looking grandfather with a mustache” and facial features rather than silhouettes. 

Regional Differences. This ad was shown only in San Antonio. Some people who saw this poster recommended that the copy be changed to read: “Get your shot today! Protect your family.”

Visual
Key Strengths
•	Photograph captures attention
•	Simple copy—clean and easy to read
Key Weaknesses
•	Preference for a photograph rather than silhouettes
•	Male should look older “like a grandfather” and should have “a mustache to make him look Latin”

Message
Key Strengths
•	Concise language is a plus
•	The message to get a flu shot was clearly understood by all
Key Weakness
•	Confusion over whether baby should get a shot, too

(7)	Concept: Extended Family. This poster was the favorite by far in the four San Antonio groups, because it shows a large extended family. “I want to see my grandchildren grow up – I will protect myself."  “The idea is good. Take care of your family, don’t just think of yourself.”  

Nondoers were not swayed, even by this appeal. “This doesn’t work—I’ve seen stuff like this before and haven’t been convinced.”

Visual
Key Strengths
•	Strong identification with a multigenerational and obviously Hispanic family
•	Clean, concise wording
Key Weakness
•	None mentioned

Message
Key Strengths
•	Protect your family resonates strongly with Hispanics, coupled with…
•	Protect myself to watch my grandchildren grow up
•	Effectively targets 65+ market
Key Weakness
•	Many still believe that the flu shot will make them sick with the flu.

(8)	Concept: True/False Worksheet. This creative concept was shown only in Chicago. It was rejected for being too long and complicated. It was replaced in San Antonio with the two ads that show families.

Visual
Key Strength
•	Information is easy to see, easy to read

Key Weakness
•	Too wordy, too much information

Message
Key Strength
•	Valuable information

   Key Weakness
•	Because of low education level of intended audience, perception that this “test” is difficult and confusing

(9)	Concept:  Reminder Postcard. Males and females in different geographic areas identify with the couple on the postcard (“you can see yourself”). The couple was described as “healthy,” “compatible,” and “trying to take care of each other.”  But a soft sell and a lot of words result in more denial on the part of nondoers, who, in extreme cases, interpreted the message as “Eat a healthy diet and you won’t get sick.” 

Visual
Key Strengths
•	Attractive layout
•	Couple is perceived as “compatible” and “trying to take care of each other”

Key Weakness
•	Too wordy

Message
Key Strength
•	Doers agree that healthy diets and lifestyles are not enough.

Key Weakness
•	Does not make sufficient impact; 20,000 deaths should be part of the headline

(10)	Concept: Promotional Items. Magnetic picture frames were the preferred promotional items (“We would see it every day on the fridge”), followed by the jar opener.

Summary Comments
While positive and negative comments were made about all items, participants’ comments suggest that promotional efforts must be extremely strong and focused, given existing educational levels, time constraints, and degree of interest in the subject. Comments that “We only read the big print” and “I can see the large print without my glasses” argue for print ads with an eye-catching picture and very little copy.

In Chicago, one of the county health workers who was watching the groups mentioned that many grandmothers care for their grandchildren during the day while their daughters work. Because of this, they may be responsive to the “protect your family” appeal.

A final note: the word for “flu” differs slightly from one Spanish-speaking location to another. In the two Chicago focus groups, people used the terms “la gripe” and “la gripa.”  In San Antonio, bilingual respondents requested that the English word “flu” also be included in the print ads.

b. Flu shot information presented to African Americans

(1)	Concept: African-American Medical Professionals—Male/Female

Visual  
Regional Differences: Males in Jackson were more likely than men in other geographic areas to believe that the female is a nurse, reinforcing the long-held stereotype that most physicians are men. However, women in Jackson preferred this female character, saying that many of their physicians are female. 

Key Strengths
•	African-American medical professional—respondents can relate to this person
•	Attire—appropriate for professional status
•	Youthful appearance—suggests they would be knowledgeable on latest scientific information
•	Female conveys “compassion”

Key Weaknesses
•	Female attire—fewer medical accoutrements (for example, badge, clipboard) suggests that female is a nurse, not a physician
•	Youthful appearance—may suggest lack of experience

Message
Key Strengths
•	Effectively identifies 65+ target market
•	New information—most respondents unaware of the seriousness of  the flu

Key Weaknesses
•	Lacks credibility for some, who did not believe a flu shot is needed annually
•	Lack of specificity about number of people killed or hospitalized
•	No information about how the flu shot helps combat flu

(2)	Concept: Man Playing Saxophone

Visual  
Gender Differences: Women want to see the facial expression of the character—eyes and smile. The vague image contributed to their lack of interest in the overall visual.  

Key Strengths
•	Connotation of strength—strong lungs to blow an instrument
•	Orange background is eye-catching

Key Weaknesses
•	Dislike fuzzy image—perhaps because of failing eyesight
•	Sax player’s ethnicity is unclear—should be clearly African American if targeted to this group 
•	More vigorous activity is required to indicate that character is in good health
•	Many respondents could not identify with this image

Message
Key Strength
•	Statistic of 20,000 deaths is credible and specific—lends a sense  of urgency

Key Weaknesses
•	Some misinterpret the overall message as defending those who do not get a flu shot
•	Statistics are “alarming,” “a scare tactic”
•	Statements are confusing, as some comments are attributed to the saxophone player while others come from an unidentified source— “Who’s doing the talking here?”

(3)	Concept: African-American Female – I’m 67

Visual
Gender Differences: Females are somewhat more likely than males to respond favorably to this female character. For women, the model reminds respondents of themselves or someone they know. 

Key Strengths
•	Strong, positive image of African-American female who is 65+
•	Visible facial expression—healthy, happy disposition
Key Weaknesses
•	None mentioned

Message
Key Strength
•	I’m 67—language gets attention, clearly indicates target audience
Key Weaknesses
•	No information to support the suggestion that a flu shot does not cause the flu
•	Does not persuade respondents that healthy people need a flu shot

(4)	Concept: African-American Female – I’m 65

Visual
Gender Differences: Females were somewhat more likely than males to respond favorably to this female character. For women, the model reminded respondents of themselves or someone they know.
Key Strengths:
•	Strong, positive image of African-American female who is 65+
•	Visible facial expression—healthy, happy disposition
Key Weaknesses
•	None mentioned

Message
Key Strength
•	Reinforces positive relationship with personal physician
Key Weaknesses
•	Need more information about why physician is recommending the shot
•	Want message to indicate how she is stronger

(5)	Concept: Gray-Haired Man with Baby

Visual
Gender Differences: Men were particularly drawn to this image of a male as protector.   
Key Strengths
•	Image of “cradling” baby conveys strength, caring, tenderness—image of a protector
•	Male character appears healthy, contented
•	Powerful to use image of African-American male involved in 
child-rearing
Key Weaknesses
•	None mentioned
Message
Key Strength
•	Powerful motivation to get the shot to protect a loved one
Key Weaknesses
•	Does the baby need a flu shot, too?
•	Many respondents believed that being in good health limits likelihood of contracting flu

(6)	Concept: Crossword Puzzle. Some regional and gender differences were noted.
Most males, particularly those in Jackson, said they would be quite unlikely to use this format or read the information. Most females liked the format because they like crossword puzzles. In Jackson, some women were tenacious in wanting to complete the crossword during the focus group.   

Visual
Key Strengths
•	Information easy to see
•	Easy to read

Key Weaknesses
•	Cluttered, wordy, too much information
•	No pictures or images to draw people into the ad

Message
Key Strengths
•	Valuable information
•	Like crossword puzzle format

Key Weakness
•	Game is not interesting; don’t like crossword puzzles

(7)	Concept:  Snapping Fingers

Visual (not included)
Key Strengths
•	Uncluttered look—not too much copy
•	Simple and clean

Key Weakness
•	Image unclear—some people didn’t know the image was a hand with snapping fingers until prompted

Message
Key Strength
•	Information is concise, to the point

Key Weaknesses
•	Who is a “provider”?  Substitute “health care provider”
•	Not persuasive in getting people to get a flu shot

(8)	Concept: Promotional Items

Because they were not available early in the project, the promotional items were shown only to respondents in Rochester and Jackson. Overall, participants did  not favor using these items. Several people said the refrigerator magnet was “cute” or “nice.” The general sentiment, however, was that promotional items would be most likely to be noticed regularly if it’s something useful, such as the jar opener. The refrigerator magnet and the jar opener received the most attention in the focus groups.

Several focus group participants did not have specific responses to the promotional items. Some respondents seemed confused because the promotional items they examined were generic; that is, the items did not incorporate any message about flu.

Summary Comments 
People perceived from the visuals showing an older African American that they are the target audience for that message. People responded most positively to healthy, happy African-American characters. A person they could personally identify with is as powerful as an image of a health care professional. Respondents paid close attention to facial expressions and body language. They responded very positively to smiling, welcoming images and less positively to images where the expression is neutral or cannot be seen clearly. Images that depict men as protectors are particularly motivating. 

They recommended that messages should avoid the absolute statements that flu shots prevent flu or that flu shots don’t cause flu, because some people do not believe these ideas. Rather, phrases like “fighting the flu” are more believable and more powerful. Also, they suggested that a question-and-answer format may be useful when educating older African Americans about flu shots.

c. Pneumonia immunization information presented to African Americans and Hispanic Americans 

These materials were presented to both African-American and Hispanic-American focus group participants.

(1)	Concept: Q&A Sheet
Visual
Key Strengths
•	None mentioned
Key Weaknesses
•	Bland, “not colorful”
•	Weak font
•	No visuals—pictures should be incorporated into the message
Message
Key Strengths
•	Information helpful and believable
•	Ideas are presented briefly and clearly
•	Easy to understand
•	Information on getting the pneumococcal polysaccharide vaccine only once every 5 to 10 years
•	Short, simple questions; answers short, to the point
Key Weaknesses
•	None mentioned

(2)	Concept: STOP!  Card
Visual (not included)
Key Strength
•	Symbol of stop sign is eye-catching and easy to identify
Key Weakness
•	No images incorporated, except stop sign
Message
Key Strength
•	Easy to read and follow
Key Weakness
•	Needs more information about pneumococcal polysaccharide vaccine

B. Physicians
As with the consumer focus groups, physicians responded to the ads presented to them and the specific questions posed in a highly consistent manner. Very few differences can be attributed to medical specialty or geography. These minor differences are noted below.

1. Issues Discussed

a. What is your personal belief about the influenza immunization?  About the pneumococcal polysaccharide vaccine?

Physicians indicated that both immunizations are important. 

A few physicians believed there is a little too much hype about the flu shot, particularly since the immunization is “hit or miss” because it can address very few of the dozens of influenza strains.

A Milwaukee cardiologist suggested that the flu shot was important only for the very elderly, persons over age 75. When presented with the information about morbidity and mortality rates associated with flu, he appeared to be shocked.

A Chicago cardiologist suggested that the pneumococcal polysaccharide vaccine is “not as good an immunization” as the flu shot, although he still recommends it. A pulmonary medicine physician in San Antonio said some of his patients have developed pneumonia, even though they received the pneumococcal polysaccharide vaccine within five years preceding the episode.

b. Do you actively recommend the flu shot and the pneumococcal polysaccharide vaccine to your healthy patients who are over age 65?  Why or why not?

All physicians agreed that the flu shot prevents disease—the flu—and its most serious complication—pneumonia. For this reason, they actively recommend the shots. A representative comment:  “There’s no downside … extremely safe and not costly.”

Some physicians believed the age threshold for recommending the immunizations should be 50, not 65. People holding this opinion think that people under age 50 should get the shots only if other disease states are present.

Some physicians do not recommend the flu shot for people with allergies, because the vaccine is cultured in eggs.

c. Do you recommend the flu shot and the pneumococcal polysaccharide vaccine for your patients who have one or more risk factors besides age?

Physicians claimed to be quite conscientious in recommending the flu shot and the pneumococcal polysaccharide vaccine to their patients who have other risk factors. 
In some cases, physicians take on this responsibility personally. In other cases, staff members—for example, the intake nurse—are responsible for screening patients then recommending and administering the shots.

Physicians cited the following as risk factors that make it more urgent for the patient to receive these immunizations:
•	Over age 65;
•	Health care worker;
•	Asthma;
•	Chronic obstructive pulmonary disease (C.O.P.D.) or some other type of recurrent respiratory infection; and
•	Some type of cardiovascular disease, H.I.V./AIDS., diabetes, cancer.

d. When you recommend immunization, what is your primary message?

The message physicians reported using most often is that flu can turn into pneumonia, which is a horrible disease. They say they have no problem convincing patients they might die if they contract pneumonia.

Some also stress that the flu vaccine is now a dead virus.

One person stated simply, “I tell my patients I take it myself.”

Doctors consistently asserted that their time with patients is quite limited. None expressed willingness to engage in a long conversation (five minutes or more) to persuade a single patient to get a flu shot. Most simply endorse the shot as a professional recommendation and quickly move on if patients do not accept this advice promptly.

e. What are the primary reasons your patients decline a flu shot?

As the consumers themselves said, physicians said their patients most often decline to be immunized because they believe the flu shot gives people the flu. While recognizing that this impression is not based on good science, physicians said they seldom spend much time arguing the point.

Some patients do not get the flu shot because they “don’t like shots” or “don’t like needles.”  Physicians speculated that a few people decline the flu shot because of their aversion to physicians.

Some patients have an “out of sight, out of mind” attitude about the flu.

For a small percentage of patients, cost is a consideration.

Some of the physicians in Jackson suggested that the media’s preoccupation with the West Nile virus (there had been some cases in the area) might have detracted attention from the flu shot.

f. Are there certain categories or types of people who are least interested in getting a flu shot?

Most physicians agreed that there is no meaningful racial, ethnic, or gender issue that distinguishes “doers” from “nondoers.”  The most consistent predictor is access to care. That is, people who have good access to a personal physician, get an annual physical, and otherwise access the health care system regularly are more interested in the flu shot and more likely to get the shot than people who only occasionally see a doctor.

Another element was that many patients who request a flu shot have had previous bouts of the flu and do not want to repeat the experience.

Some physicians indicated that the most compliant patients are better educated, read a lot, and care about their health.

Some doctors said they have more problems with “mature” patients. They say mature patients, particularly older men, are less aggressive in seeking health care and rarely make doctor’s appointments.

A few physicians reported that noncompliant patients, particularly African Americans, are sometimes “afraid of the government” and any government-sponsored or government-endorsed immunization program. Physicians suggested that African-American patients who are distrustful are more likely to accept the recommendations of an African-American physician.

g. What strategies would you recommend for increasing immunization rates among African Americans and Hispanic Americans?

Physicians said that increasing immunization rates depends on conveying better information about flu and pneumonia. They thought many patients do not recognize the seriousness of the flu or that people are more susceptible to flu and its complications as they age.

Many physicians agreed that churches and community centers are good places to provide information/increase awareness and also to give the flu shot. Some physicians also recommended mobile units to deliver the flu shot to neighborhoods and workplaces.

There was consensus that any message to the public designed to encourage people to get a flu shot should be “simple advice.”

A few doctors spontaneously recommended giving incentives to physicians to “push the flu shot.”

Some physicians thought that conventional advertising—radio, television, newspaper— targeting a broad audience could effectively supplement and support the information that physicians and other health care workers provide personally.

Physicians felt strongly that cost should not be a barrier: “Give the flu shots away” to increase immunization rates.

h. Are providers adequately reimbursed for administering the influenza vaccine?

Most physicians, particularly those who are employees of health systems or specialists (pulmonary medicine or cardiology), had no idea what their offices charge for a flu shot. The revenue that can be generated from giving flu shots is not a significant part of their decision-making process about whether to encourage patients to get the shot. One physician said, “I could make more money changing tires than I make giving flu shots.”

Some primary care physicians, particularly those in small practices (three physicians or fewer), were more attuned to the financial component of the practice. They knew what they charge to give the shot (generally, $12–$15) and their profit margin (around $3). 

Some physicians described administering immunizations as “a hassle,” especially because patients have to complete paperwork, such as a consent form.

i. Do you think providers should receive financial incentives for being more diligent in encouraging patients to get a flu shot?

Some of the physicians in smaller practices reported that they might be motivated to be more tenacious about talking with their patients if payment were more lucrative. For an equal or greater number, the level of payment/reimbursement for giving the shot is totally unimportant. Said one person; “It’s not a contest for money.”

A number of physicians said that outside encouragement for administering an annual flu shot should be directed to intake nurses and other personnel as well as physicians. Some also suggested that this emphasis might be most effective if directed to first-line providers—visiting nurses, health department nurses—in settings outside physicians’ private practices.

Some physicians felt strongly that offering financial incentives to physicians is a poor strategy. These physicians saw this approach as “paying you to do what you’re supposed to be doing anyway.”  They believe this strategy might damage trust between them and 
their patients, creating the impression that they encourage patients to get a flu shot only in order to make money.

More than one clinician believed that C.D.C. should sponsor a pilot program of offering incentives to physicians and measuring whether this affects patient compliance.

j. Do you use a systematic method for ensuring that your patients get a flu shot or the pneumococcal polysaccharide vaccine? How often do you screen the vaccination status of patients? Do you maintain an immunization record in the chart? Do you use a reminder recall system for flu shots?

Most physicians indicated that their offices have some mechanism for tracking patients’ immunizations. One physician hand writes the date of each patient’s most recent pneumococcal polysaccharide vaccine on the cover of the patient’s chart. Most practices keep some sort of immunization records as part of the problem list or some other part of each patient’s chart.

Some physicians honestly admitted that they do not have a system for tracking immunizations. Many of these people said it would be cost-prohibitive to maintain such a system.

Doctors often use informal methods to encourage immunizations. Some primary care physicians try to set a high volume of patient visits in October and November as a way of making sure their patients get a flu shot during that office visit. Others assess patient need for the pneumococcal polysaccharide vaccine each year when the patient comes in for an annual physical.

There is general agreement that long-term electronic medical records can offer an easy-to-use mechanism for tracking immunizations and creating red flags in the records for patients who need shots.

There seems to be a meaningful difference between primary care physicians (PCPs), including family medicine and internal medicine, and the other medical specialties represented in the interviews. In general, PCPs were much more attuned to immunizations. PCPs seem to keep more accurate records and to feel a greater level of personal responsibility for endorsing the flu shot and the pneumococcal polysaccharide vaccine to their patients.

k. Do you have standing orders that would allow your staff to give a flu shot to anyone who requests one even without seeing you?

Many P.C.Ps use standing orders. In contrast, some cardiologists and pulmonary medicine physicians do not have standing orders because administering flu shots “does not apply to me.”

Some primary care physicians, particularly those who recommend the flu shot only for “really elderly” patients, believed that patients should have a brief physician encounter before receiving a flu shot.

l. Do you ever refer patients to a pharmacy, grocery story, public health clinic or other source to get their flu shot?

When physicians refer patients to these other sources, they most often do so for financial reasons—the patient is uninsured or insurance will not cover the shot. Some said they refer patients to these sources because grocery stores and other facilities may have access to the flu shot when physician offices do not.

2. Preferred Communication Methods 

Acknowledging that physicians are inundated with mail, sales materials, and other communications, the interviewers asked each physician to identify the most effective ways to communicate important messages to them and their colleagues. Respondents suggested:
•	Articles in scientific journals (peer-reviewed, not commercial);
•	Advertising in The New England Journal of Medicine;
•	For large practices, direct contact with clinic managers or practice administrators;
•	Data/presentations at meetings/symposia;
•	Mail sent to physicians’ home addresses—a personally addressed letter;
•	Medical societies—sending out reminder notices;
•	Face-to-face visits (because this is the mechanism they use with pharmaceutical reps); and
•	Memos or other materials from hospitals where physicians practice.

3. Impression of C.D.C. 

Physicians unanimously agreed that C.D.C. is a reliable, trusted source of information. Some said they comply with requests for action “just because it’s C.D.C.”

Physicians also had positive histories with materials they have received from C.D.C. Several people commented positively about the literature sent on overuse of antibiotics. They agreed that similar straightforward, high-quality materials should be developed about the flu shot and the pneumococcal polysaccharide vaccine. 

Some physicians said they have a “love-hate relationship” with C.D.C. They respect many of the individuals who work for the organization. Several people specifically praised C.D.Cs website and the advisories posted on the website. Still others were sympathetic to C.D.Cs current funding levels. 

During this line of questioning, some physicians mentioned that they had difficulty getting information from C.D.C. by phone. Some also expressed frustration about the distribution of limited vaccine during the past two years.

4. Materials Tested

a. Postcards. Several physicians were confused about the intent of the postcards, presuming that these were materials that would be sent to patients, not to physicians themselves. 

Message
When reviewing the message, which was the same for all three cards presented, some physicians said they liked the statistics provided. For some, particularly physicians in cardiology, this was new information.

One physician, who was surprised by the information about deaths and hospitalizations, suggested that a reference source or basis of calculation for these data be included. Some physicians believed numbers and statistics mean little to their patients.

More than one physician stated forcefully that it is unnecessary to tell physicians the “the flu shot cannot give you the flu.”  

(1)	Postcard #1:  “More than a bad cold!”   
Key Strengths
•	Kleenex has a direct relationship to upper respiratory infections
•	Informative and understandable
Key Weaknesses
•	Image is unclear: “Is it a block of cheese?” “looks like cheesecake”
•	Image doesn’t capture or maintain interest
•	Kleenex—connotation of crying?

(2)	Postcard #2:  “It takes more … Educate.”   
Key Strengths
•	None mentioned
Key Weaknesses
•	Confusing—don’t understand what the visual connotes
•	What does a pile of apples mean?
•	Creative concept hard to comprehend
•	Looks “too busy”
•	Are they apples or a bunch of cherries?

(3)	Postcard #3:  “Good in theory.” 
Key Strengths
•	Eye-catching
•	Understand the logic
•	Simple, gets right to the point
Key Weakness
•	Image is “really a stretch”

b. Posters. Physicians also reviewed mock-ups of posters that might be placed in their waiting rooms or elsewhere in physicians’ offices.

(1)	Poster:  Philomena Cisneros   
Key Strength
•	Gives information at a glance
Key Weaknesses
•	Should have a Spanish version 
•	Picture looks out of focus
•	Point, purpose is not clear: Did she get the flu?  Why did she get it?
•	Vocabulary much too difficult for the typical patient

(2)	Poster:  Crossword Puzzle   
Key Strength
•	Could be useful to educate patients
Key Weaknesses
•	Looks like too much work
•	Don’t challenge patients; they get upset if they can’t do it
•	Could be intimidating
•	Patients should be the ones asking the questions in the doctor’s office
•	The education level you should be targeting does not have the vocabulary to do crossword puzzles

Physicians suggested improving this poster by incorporating an image that includes all three races. Some suggested using a message that endorses immunization for both flu and pneumonia on the same poster.

c. Promotional Items. As with the postcards, physicians were unclear about whether the promotional items were designed for them or their patients. However, they consistently objected to using these types of items, equating them with marketing strategies used by the drug companies. 

Many physicians said they receive these items incessantly from the drug companies:  “I get a billion pens … all the same.”

Physicians agree that any promotional items should “not be too advertise-y.”

(1)	Promotional Item: Stress reliever/squeezie   
Key Strengths
•	Cute
•	Something to play with
Key Weakness
•	Childish

(2)	Promotional Item: Calendar strip on computer
While some said the item “might be helpful,” others did not think they would use it. Respondents did not identify any specific strengths or weaknesses for this item.  

(3)	Promotional Item: Breath mints   
Most say this item would have “no lasting effect.”
Key Strength
•	Most physicians are men: “We like to eat stuff”
Key Weakness
•	Not useful for this purpose—would eat the mints and throw the wrapper away

d. Information brochure: Increasing Influenza and Pneumococcal Vaccination Coverage. Physicians endorsed a document that is shorter and simpler than the version presented. They prefer visuals, charts, and graphs to narrative copy.  
Key Strengths
•	Like the myths section
•	Like the image: “a patient you don’t want to lose”
Key Weaknesses
•	Need short, simple name for brochure
•	“Never sit down and read a brochure … don’t have time”

Summary Comments
Physicians did not consistently praise any of the concepts. They recommend that C.D.C. distribute a single-page flyer that they can give to patients, with C.D.C.’s logo appearing prominently. Ideally, they want this handout to:
•	Be on one side of one 8.5” x 11” page;
•	Use a clean layout (for example, bullet points);
•	Include an 800 number so patients can get additional information without contacting the physician’s office; and
•	Be available in Spanish and English.

APPENDIX A:
SCREENERS FOR CONSUMER FOCUS GROUPS

August 1, 2002
Recruit 10 per group for 8 to show

Screener for Focus Groups – Chicago, Illinois

Hello, my name is (fill in blank) with (fill in blank), a market research firm. Today, we are talking with people like you about the flu vaccine and whether they plan to get it this fall. To see if you qualify for a discussion group, I need to ask you a few questions. 

1.		Are you, or is anyone in your immediate family, employed in the following 				industries? (IF YES TO ANY, THANK AND TERMINATE)
01  Advertising or public relations
02	Market research
03	Physician
04	Nurse
05	None (CONTINUE)

2.	What is your race or ethnicity? 
	01	Caucasian/European American (THANK AND TERMINATE) 
	02	African American (PLACE IN APPROPRIATE GROUP)
	03	Hispanic American (PLACE IN APPROPRIATE GROUP)
	04	Asian American  (THANK AND TERMINATE)
96	Other (THANK AND TERMINATE)

3.	In an average week, do you watch/listen to FIVE or more hours of television or radio?
	01 Yes (CONTINUE)
	02 No (THANK AND TERMINATE)

4.	What is your age group?  Are you:
	01  64 or younger (THANK AND TERMINATE)
02	65 or older (CONTINUE)

[HISPANIC AMERICAN ONLY]
5.	Is your annual household income above $33,000 per year or below $33,000 per 	year?
	01 Above $33,000 (RECRUIT AT LEAST FOUR PER GROUP)
	02 Below $33,000 (RECRUIT AT LEAST FOUR PER GROUP)

[AFRICAN AMERICAN ONLY]
6.	Is your annual household income above $30,000 per year or below $30,000 per 	year?
	01 Above $30,000 (RECRUIT AT LEAST FOUR PER GROUP)
	02 Below $30,000 (RECRUIT AT LEAST FOUR PER GROUP)

7.	How likely are you to get a flu shot this year? Are you: 
	01 Very likely (CONTINUE)
	02 Somewhat likely (CONTINUE)
03	Not sure (THANK AND TERMINATE)
04	Somewhat unlikely (CONTINUE)
05	Very unlikely (CONTINUE)

[IF ANSWER TO #7 IS “SOMEWHAT UNLIKELY” OR “VERY UNLIKELY”]
8.	Are you allergic to the flu shot or do you have some other medical reason for not 	getting a flu shot this year?	
	01 Yes (THANK AND TERMINATE)
	02 No (CONTINUE)

9.	Have you participated in a focus group or some other type of market research in the past six months?Yes (THANK AND  TERMINATE)
01	No

10.	[DOCUMENT GENDER – RECRUIT FOR APPROPRIATE GROUP]
	01 Female
	02 Male

The group discussion will be held on (fill in blank) at (fill in blank) pm and will last for approximately two hours. Because we know your time is valuable, at the end of the discussion we will pay you $60 for participating. Are you willing to attend?  
01	Yes
02	No (THANK AND TERMINATE)

Name (fill in blank)
Address (fill in blank)   
City/State/Zip (fill in blank)
Day Number (fill in blank)   Night Number (fill in blank)

Tuesday, August 20
2:00 pm – Hispanic-American Male – NOT likely to get flu shot
4:00 pm – Hispanic-American Female – NOT likely to get flu shot
2:00 pm – African-American Male – NOT likely to get flu shot
4:00 pm – African-American Female – NOT likely to get flu shot

Wednesday, August 21

2:00 pm – Hispanic-American Male – likely to get flu shot
4:00 pm – Hispanic-American Female – likely to get flu shot

August 1, 2002	
Recruit 10 per group for 8 to show

Screener for Focus Groups – Jackson, Mississippi

Hello, my name is (fill in blank) with (fill in blank), a market research firm. Today we are talking with people like you about the flu vaccine and whether they plan to get it this fall. To see if you qualify for a discussion group, I need to ask you a few questions. 

1.		Are you, or is anyone in your immediate family, employed in the following 				industries? (IF YES TO ANew York, THANK AND TERMINATE)
01 Advertising or public relations
02 Market research
03 Physician
04 Nurse
05 None (CONTINUE)

2.	What is your race or ethnicity? 
	01	Caucasian/European American (THANK AND TERMINATE) 
	02	African American (PLACE IN APPROPRIATE GROUP)
	03	Hispanic American (THANK AND TERMINATE)
	04	Asian American  (THANK AND TERMINATE)
97	Other (THANK AND TERMINATE)

3.	What is your age group?  Are you:
	01  64 or younger (THANK AND TERMINATE)
	02  65 or older (CONTINUE)

4.	In an average week, do you watch/listen to five or more hours of television or 	radio?
	01 Yes (CONTINUE)
	02 No (THANK AND TERMINATE)

5.	Is your annual household income above $30,000 per year or below $30,000 per 	year?
	01 Above $30,000 (RECRUIT AT LEAST FOUR PER GROUP)
	02 Below $30,000 (RECRUIT AT LEAST FOUR PER GROUP)

6.	How likely are you to get a flu shot this year?  Are you:
	01 Very likely (CONTINUE)
	02 Somewhat likely (CONTINUE)
	03 Not sure (THANK AND TERMINATE)
	04 Somewhat unlikely (CONTINUE)
	05 Very unlikely (CONTINUE)
[IF ANSWER TO #6 IS “SOMEWHAT UNLIKELY” OR “VERY UNLIKELY”]

7.	Are you allergic to the flu shot or do you have some other medical reason for not 	getting a flu shot this year?	
	01 Yes (THANK AND TERMINATE)
	02 No (CONTINUE)

8.	Have you participated in a focus group or some other type of market research in 	the past six months?
	01 Yes (THANK AND TERMINATE)
	02 No

9.	Do you live in Hinds County?
	01 Yes (CONTINUE)
	02 No (RECRUIT AT LEAST TWO)

10.	[DOCUMENT GENDER – RECRUIT FOR APPROPRIATE GROUP]
	01 Female
	02 Male

The group discussion will be held on (fill in blank) at (fill in blank) pm and will last for approximately two hours. Because we know your time is valuable, at the end of the discussion we will pay you $60 for participating. Are you willing to attend?
01 Yes
02 No (THANK AND TERMINATE)

Name (fill in blank)
Address (fill in blank)  
City/State/Zip (fill in blank)
Day Number (fill in blank)    Night Number (fill in blank)

Monday, August 26
2:00 pm – African-American Male – NOT likely to get flu shot
4:00 pm – African-American Female – NOT likely to get flu shot

Tuesday, August 27
2:00 pm – African-American Male – likely to get flu shot
4:00 pm – African-American Female – likely to get flu shot

August 1, 2002
Recruit 10 per group for 8 to show

Screener for Focus Groups – Milwaukee, Wisconsin

Hello, my name is (fill in blank) with (fill in blank), a market research firm. Today, we are talking with people like you about the flu vaccine and whether they plan to get it this Fall. To see if you qualify for a discussion group, I need to ask you a few questions. 

1.		Are you, or is anyone in your immediate family, employed in the following 				industries? (IF YES TO ANew York, THANK AND TERMINATE)
01 Advertising or public relations
02 Market research
03 Physician
04 Nurse
05 None (CONTINUE)

2.	What is your race or ethnicity? 
	01	Caucasian/European American (THANK AND TERMINATE) 
	02	African American (PLACE IN APPROPRIATE GROUP)
	03	Hispanic American (THANK AND TERMINATE)
	04	Asian American  (THANK AND TERMINATE)
98	Other (THANK AND TERMINATE)

3.	What is your age group?  Are you:
	01  64 or younger (THANK AND TERMINATE)
	02  65 or older (CONTINUE)

4.	In an average week, do you watch/listen to five or more hours of television or radio?
	01 Yes (CONTINUE)
	02 No (THANK AND TERMINATE)

5.	Is your annual household income above $30,000 per year or below $30,000 per year?
	01 Above $30,000 (RECRUIT AT LEAST FOUR PER GROUP)
	02 Below $30,000 (RECRUIT AT LEAST FOUR PER GROUP)

6.	How likely are you to get a flu shot this year?  Are you:
	01 Very likely (THANK AND TERMINATE)
	02 Somewhat likely (THANK AND TERMINATE)
	03 Not sure (THANK AND TERMINATE)
	04 Somewhat unlikely (CONTINUE)
	05 Very unlikely (CONTINUE)
[IF ANSWER TO #6 IS “SOMEWHAT UNLIKELY” OR “VERY UNLIKELY”]

7.	Are you allergic to the flu shot or do you have some other medical reason for not 	getting a flu shot this year?	
	01 Yes (THANK AND TERMINATE)
	02 No (CONTINUE)

8.	Have you participated in a focus group or some other type of market research in 	the past six months?
	01Yes (THANK AND TERMINATE)
	02 No

9.	[DOCUMENT GENDER – RECRUIT FOR APPROPRIATE GROUP]
	01 Female
	02 Male

The group discussion will be held on (fill in blank) at (fill in blank) pm and will last for approximately two hours. Because we know your time is valuable, at the end of the discussion we will pay you $60 for participating. Are you willing to attend?  
03	Yes
04	No (THANK AND TERMINATE)

Name (fill in blank)
Address (fill in blank)   
City/State/Zip (fill in blank)
Day Number (fill in blank)     Night Number (fill in blank)

Wednesday, August 21
2:00 pm – African-American Male – NOT likely to get flu shot
4:00 pm – African-American Female – NOT likely to get flu shot
August 1, 2002	

Recruit 10 per group for 8 to show

Screener for Focus Groups – Rochester, New York

Hello, my name is (fill in blank) with (fill in blank), a market research firm. Today, we are talking with people like you about the flu vaccine and whether they plan to get it this fall. To see if you qualify for a discussion group, I need to ask you a few questions. 

1.		Are you, or is anyone in your immediate family, employed in the following 				industries? (IF YES TO ANew York, THANK AND TERMINATE)
01  Advertising or public relations
02 Market research
03 Physician
04 Nurse
05 None (CONTINUE)

2.	What is your race or ethnicity? 
	01	Caucasian/European American (THANK AND TERMINATE) 
	02	African American (PLACE IN APPROPRIATE GROUP)
	03	Hispanic American (THANK AND TERMINATE)
	04	Asian American  (THANK AND TERMINATE)
99	Other (THANK AND TERMINATE)

3.	What is your age group?  Are you:
	01 64 or younger (THANK AND TERMINATE)
	02 65 or older (CONTINUE)

4.	In an average week, do you watch/listen to five or more hours of television or 	radio?
	01 Yes (CONTINUE)
	02 No (THANK AND TERMINATE)

5.	Is your annual household income above $30,000 per year or below $30,000 per 	year?
	01 Above $30,000 (RECRUIT AT LEAST FOUR PER GROUP)
	02 Below $30,000 (RECRUIT AT LEAST FOUR PER GROUP)

6.	How likely are you to get a flu shot this year?  Are you:
	01 Very likely (THANK AND TERMINATE)
	02 Somewhat likely (THANK AND TERMINATE)
	03 Not sure (THANK AND TERMINATE)
	04 Somewhat unlikely (CONTINUE)
	05 Very unlikely (CONTINUE)
[IF ANSWER TO #6 IS “SOMEWHAT UNLIKELY” OR “VERY UNLIKELY”]

7.	Are you allergic to the flu shot or do you have some other medical reason for not 	getting a flu shot this year?	
	01 Yes (THANK AND TERMINATE)
	02 No (CONTINUE)

8.	Have you participated in a focus group or some other type of market research in 	the past six months?
	01 Yes (THANK AND TERMINATE)
	02 No

9.	[DOCUMENT GENDER – RECRUIT FOR APPROPRIATE GROUP]
	01 Female
	02 Male

The group discussion will be held on (fill in blank) at (fill in blank) pm and will last for approximately two hours. Because we know your time is valuable, at the end of the discussion we will pay you $60 for participating. Are you willing to attend? 
01 Yes
02 No (THANK AND TERMINATE)

Name (fill in blank)

Address (fill in blank)   

City/State/Zip (fill in blank)

Day Number (fill in blank)   Night Number (fill in blank)

Thursday, August 22
2:00 pm – African-American Male – NOT likely to get flu shot
4:00 pm – African-American Female – NOT likely to get flu shot

August 1, 2002		
Recruit 10 per group for 8 to show

Screener for Focus Groups – San Antonio, Texas

Hello, my name is (fill in blank)_with (fill in blank), a market research firm. Today, we are talking with people like you about the flu vaccine and whether they plan to get it this fall. To see if you qualify for a discussion group, I need to ask you a few questions. 

1.		Are you, or is anyone in your immediate family, employed in the following 				industries? (IF YES TO ANew York, THANK AND TERMINATE)
01 Advertising or public relations
02 Market research
03 Physician
04 Nurse
05 None (CONTINUE)

2.	What is your race or ethnicity? 
	01	Caucasian/European American (THANK AND TERMINATE) 
	02	African American (THANK AND TERMINATE)
	03	Hispanic American (PLACE IN APPROPRIATE GROUP)
	04	Asian American  (THANK AND TERMINATE)
	99  Other (THANK AND TERMINATE)

3.	What is your age group?  Are you:
	01  64 or younger (THANK AND TERMINATE)
	02  65 or older (CONTINUE)

4.	In an average week, do you watch/listen to five or more hours of Hispanic television or radio?
	01 Yes (CONTINUE)
	02 No (THANK AND TERMINATE)

5.	Is your annual household income above $33,000 per year or below $33,000 per 	year?
	01 Above $33,000 (RECRUIT AT LEAST FOUR PER GROUP)
	02 Below $33,000 (RECRUIT AT LEAST FOUR PER GROUP)

6.	How likely are you to get a flu shot this year?  Are you:
	01 Very likely (CONTINUE)
	02 Somewhat likely (CONTINUE)
	03 Not sure (THANK AND TERMINATE)
	04 Somewhat unlikely (CONTINUE)
	05 Very unlikely (CONTINUE)
[IF ANSWER TO #6 IS “SOMEWHAT UNLIKELY” OR “VERY UNLIKELY”]

7.	Are you allergic to the flu shot or do you have some other medical reason for not 	getting a flu shot this year?	
	01 Yes (THANK AND TERMINATE)
	02 No (CONTINUE)

8.	Have you participated in a focus group or some other type of market research in 	the past six months?
	01 Yes (THANK AND TERMINATE)
	02 No

9.	[DOCUMENT GENDER – RECRUIT FOR APPROPRIATE GROUP]
	01 Female
	02 Male

The group discussion will be held on (fill in blank) at (fill in blank) pm and will last for approximately two hours. Because we know your time is valuable, at the end of the discussion we will pay you $60 for participating. Are you willing to attend? 
01 Yes
02 No (THANK AND TERMINATE)

Name (fill in blank)

Address (fill in blank)   

City/State/Zip (fill in blank)

Day Number (fill in blank)    Night Number (fill in blank)

Monday, August 26
2:00 pm – Hispanic-American Male – NOT likely to get flu shot
4:00 pm – Hispanic-American Female – NOT likely to get flu shot

Tuesday, August 27
2:00 pm – Hispanic-American Male – likely to get flu shot
4:00 pm – Hispanic-American Female – likely to get flu shot

APPENDIX B:
SCREENER FOR PHYSICIAN INTERVIEWS

Hello, my name is (fill in blank) with (fill in blank), a market research firm. Today we are talking with people like you about encouraging high-risk patients to get the flu vaccine this fall. This conversation is sponsored by the Centers for Disease Control and Prevention. To see if you qualify for an interview, I need to ask you a few questions. 

1. Is anyone in your immediate family employed in the following industries? (IF YES TO ANew York, THANK AND TERMINATE)
01  Advertising or public relations
02 Market research
03 None (CONTINUE)

2.  In what specialty or specialties do you practice?
	01 Family Practice/Family Medicine (RECRUIT ONE)
02	Internal Medicine (RECRUIT ONE)
03	Cardiology (RECRUIT ONE)
04	Pulmonary Medicine (RECRUIT ONE)
05	Other Specialty (THANK AND TERMINATE)

[FOR FAMIllinoisY PRACTICE AND INTERNAL MEDICINE ONLY]
3.   Are at least one-third of your patients African American?
	01 Yes
	02 No (THANK AND TERMINATE)

[FOR FAMIllinoisY PRACTICE AND INTERNAL MEDICINE ONLY]
4.  Are at least one-third of your patients 65 or older?
	01 Yes
	02 No (THANK AND TERMINATE)

5.	Have you participated in a market research focus group or interview for any 	purpose during the past six months?
01  Yes (THANK AND TERMINATE)
	02  No

Your interview will be held on (fill in blank) at (fill in blank) pm and will last for approximately one hour. Because we know your time is valuable, at the end of the discussion we will pay you $200 for participating. Are you willing to attend?  
05	Yes
06	No (THANK AND TERMINATE)

Name (fill in blank)

Address (fill in blank)   

City/State/Zip (fill in blank)

Day Number (fill in blank)     Night Number (fill in blank)

APPENDIX C:
MODERATORS’ GUIDES FOR CONSUMER FOCUS GROUPS
Participants:  African Americans 65 years and older

Warm-up Questions (5–10 minutes)
1.	What health issues concern you most?
2.	What diseases appear in the fall and winter months?
3.	How do you avoid contracting these diseases?

Flu Knowledge Questions (10 minutes)
1.	What is the flu?
a.	How do you get the flu?
2.	What are the signs and symptoms of the flu?
a.	How do you know you have the flu and not some other illness such as a cold?
b.	If you get influenza, how long does your sickness last?
3.	Do you consider influenza to be a serious illness?  
a.	Why or why not?
b.	Can influenza cause death?
4.	What do you do to avoid getting the flu?

Flu Beliefs and Behavior (20–25 minutes)

1.	Have you ever heard about the influenza or “flu” shot?
a.	What have you heard?
2.	Who do you believe would benefit most from getting a flu shot?
3.	Did you get a flu shot last flu season?
a.	Why or why not?
4.	Do you plan to get a flu shot this season?
a.	Why or why not?
b.	How do you determine if you need a flu shot?
c.	Does your health insurance pay for a flu shot?
5.	Where do you get your information about flu shots?
a.	Probe for sources of information such as media, friends, family, church
6.	Has your doctor talked with you about the flu shot?
a.	What did he or she tell you?
b.	What benefits, if any, are there to the flu shot?
c.	Do you believe that a flu shot will protect you from getting the flu?
7.	Do you think a flu shot is really necessary?
a.	How often do you need one?
b.	Do you think some people believe a flu shot is not necessary?
8.	If you were trying to make up your mind about getting a flu shot, who would influence you?
9.	Suppose you were trying to encourage a friend to get a flu shot—what would you say?
a.	Probe for benefits and ways to overcome barriers
10.	Doctors are interested in knowing what they can say to motivate patients to get flu shots—what is your advice to them? That is, what should doctors tell people if they want them to get a flu shot?

Materials Testing (30 minutes)

Crossword Puzzle
	Describe this as a crossword puzzle that someone might find in the waiting room 	at their doctor’s office. 
	Ask:
1.	What do you think this worksheet is saying?
2.	Was it easy to understand the worksheet?
3.	Do you believe what it is saying?
4.	What do you like or dislike about this worksheet?
a.	Probe around message, phraseology, layout, number of questions, and colors
5.	Does the worksheet influence you one way or the other about getting a flu shot?
6.	Are there questions missing that you would like to see added?

“It’s a Snap” Poster
1.	What do you think this message is saying?
2.	Is this poster easy for to understand?
3.	Do you believe what it is saying?
4.	What do you like or dislike about the message or photograph?
a.	Probe about layout, colors, the photo 
5.	Does this poster influence you one way or the other about getting a 	flu shot?

“So You Don’t Think” Poster (man with baby)
1.	What do you think this message is saying?
2.	Is this poster easy to understand?
3.	Do you believe what it is saying?
4.	What do you like or dislike about the message or photograph?
b.	Probe about layout, colors, the photograph
5.	Does this poster influence you one way or the other about getting a 	flu shot?

Three Personal Stories Posters (woman in purple, woman in red, and man with saxophone)

1.	Look at these posters and read them over. Then RANK THEM FROM 1 to 3, with 1 being your favorite.
2.	What do you think these messages are saying?
3.	Are these posters easy to understand?
4.	Do you believe what they are saying?
5.	What do you like or dislike about the message or photographs?
a.	Probe about layout, colors, the photographs
6.	Do these posters influence you one way or the other about getting a 	flu shot?

Physician Posters
1.	Look at these posters and read them. Decide which is your favorite
a. Why?
2.	What do you think this message is saying?
3.	Are these posters easy to understand?
4.	Do you believe what they are saying?
5.	What do you like or dislike about the message or photographs?
a.	Probe about layout, colors, the photographs, and age/gender of doctor
6.	Do these posters influence you one way or the other about getting a 	flu shot?

Spokespeople (5–10 minutes)
Show the African-American doctor posters, African-American stars, and the photos of the women in red and purple
1.	Are they believable?  Do they seem trustworthy?
2.	Who do you think would be a good spokesperson to use to convince you and your friends to get an annual flu shot?
a.	Who would have the ability to influence you?
b.	Would it be a physician, celebrity, a religious or spiritual leader, or someone like yourself?

Promotional Items and Materials Preference (5–10 minutes)
1.	How do you prefer to see health information presented?  In what form? (SHOW POSTERS, BROCHURES, FLYERS)
2.	What kinds of promotional items would you use?  (SHOW ITEMS)

Pneumococcal Questions (15–20 minutes)
1.	Have you heard about the pneumonia shot?
a.	What have you heard about it (benefits and drawbacks)?
b.	Where did you hear about it?
c.	What are your feelings and beliefs about getting a pneumonia shot?

2.	Has anyone encouraged you to get a pneumonia shot?  
a.	Who?
3.	Do you know who should get this shot (that is, who it is recommended for)?
4.	Have you ever gotten a pneumonia shot?
a.	Probe for circumstances
5.	The pneumonia shot is recommended for people 65 and over and for younger people with medical conditions such as heart disease and lung disease. This vaccine prevents complications and deaths from pneumonia. 
a.	Would you consider getting it?  Why or why not?
6.	For those of you who have not had this shot, can you tell me why?
a.	Do you have specific reasons?
b.	What would make you more willing to get this shot?

Pneumococcal Materials  (5 minutes)

“Stop” Card
1.	What do you think this message is saying?
2.	Is this card easy to understand?
3.	Do you believe what it is saying?
4.	What do you like or dislike about the message?
a.	Probe about layout, colors, the photo 
5.	Does this card influence you one way or the other about getting a flu shot?

“Questions about the Pneumonia Shot”
1.	What do you think this message is saying?
2.	Is this flyer easy to understand?
3.	Do you believe what it is saying?
4.	What do you like or dislike about the message?
a.	Probe about layout, colors, the photo
5.	Does this flyer influence you one way or the other about getting a flu shot? 

Focus Group Moderator’s Guide
Participants:  Hispanic Americans 65 years and older

Warm-up Questions (5–10 minutes)
1.	What health issues concern you most?
2.	What diseases appear in the fall and winter months?
3.	How do you avoid contracting these diseases?

Flu Knowledge Questions (10 minutes)
1.	What is the flu?
a.	How do you get the flu?
2.	What are the signs and symptoms of the flu?
a.	How do you know you have the flu and not some other illness, such as a cold?
b.	If you get influenza, how long does your sickness last?
3.	Do you consider influenza to be a serious illness?  
a.	Why or why not?
b.	Can influenza cause death?
4.	What do you do to avoid getting the flu?

Flu Beliefs and Behavior (20–25 minutes)
1.	Have you ever heard about the flu shot?
a.	What have you heard?
2.	Who do you believe would benefit most from getting a flu shot?
3.	Did you get a flu shot last flu season?
a.	Why or why not?
4.	Do you plan to get a flu shot this season?
a.	Why or why not?
b.	How do you determine whether you need a flu shot?
c.	Does your health insurance pay for a flu shot?     	
5.	Where do you get your information about flu shots?
a.	Probe for sources of information, such as media, friends, family, church
6.	Has your doctor talked with you about the flu shot?
a.	What did he or she tell you?
b.	What benefits, if any, are there to the flu shot?
c.	Do you believe that a flu shot will protect you from getting the flu?
7.	Do you think the influenza shot is really necessary?
a.	How often do you need one?
b.	Do you think some people believe a flu shot is not necessary?
8.	If you were trying to make up your mind about getting a flu shot, who would influence you?
9.	Suppose you were trying to encourage a friend to get a flu shot—what would you say?
a.	Probe for benefits and ways to overcome barriers
10.	Doctors are interested in knowing what they can say to motivate patients to get flu shots. What is your advice to them?  That is, what should doctors tell people if they want them to get a flu shot?
Materials Testing (30 minutes)

Fact Posters (2)
For each poster, ask:
1.	What do you think this message is saying?
2.	Was it easy to understand the poster?
3.	Do you believe what it is saying?
4.	What do you like or dislike about this poster?
a.	Probe around message, layout, and colors
5.	Does the poster influence you one way or the other about getting a flu shot?
a.	How and why?

True or False Worksheet
	Describe this as a worksheet that someone might find in the waiting room at their 	doctor’s office. 
	Ask:
1.	What do you think this message is saying?
2.	Was it easy to understand the worksheet?
3.	Do you believe what it is saying?
4.	What do you like or dislike about this worksheet?
a.	Probe around message, phraseology,  layout, number of questions, and colors
5.	Does the worksheet influence you one way or the other about getting a flu shot?
6.	Are questions missing that you would like to see added?

Reminder Postcard
	For this piece, have them look at the FRONT first and ask:
1.	What do you think this message is saying?
2.	Is this postcard easy to understand?
3.	Do you believe what it is saying?
4.	What do you like or dislike about the message or photograph?
a.	Probe about layout, colors, the photo of the couple in the pictures
Have them look at the BACK
5.	Does this postcard influence you one way or the other about getting a flu
 shot?
6.	Have you ever received these kinds of reminders in the mail? 

Manuel Ramirez Poster
1.	What do you think this message is saying?
2.	Is this poster easy to understand?
3.	Do you believe what it is saying?
4.	What do you like or dislike about the message or photograph?
a.	Probe about layout, colors, the photograph
5.	Does this poster influence you one way or the other about getting a flu
 shot?

“So You Think” Poster
1.	What do you think this message is saying?
2.	Is this poster easy to understand?
3.	Do you believe what it is saying?
4.	What do you like or dislike about the message or photograph?
a.	Probe about layout, colors, the photograph
5.	Does this poster influence you one way or the other about getting a 	flu shot?

Spokespeople (5–10 minutes)
Show photos of Hispanic doctor, Hispanic stars, and the photos of Manuel Ramirez and the woman on the “So You Think” poster. 
1.	Are they believable?  Do they seem trustworthy?
2.	Who would be a good spokesperson to use to convince you and your friends to get a flu shot?
a.	Who would have the ability to influence you?
b.	Would it be a physician, celebrity, a religious or spiritual leader, or someone like yourself?

Promotional Items and Materials Preference (5–10 minutes)
1.	How do you prefer to see health information presented?  In what form?
2.	What kinds of promotional items would you use?  (SHOW ITEMS)

Pneumococcal Questions (15–20 minutes)
1.	Have you heard about the pneumonia shot?
a.	What have you heard about it (benefits and drawbacks)?
b.	Where did you hear about it?
c.	What are your feelings and beliefs about getting a pneumonia shot?
2.	Has anyone encouraged you to get a pneumonia shot?  
a.	Who?
3.	Do you know who should get a shot (that is, who it is recommended for)?
4.	Have you ever gotten a pneumonia shot?
a.	Probe for circumstances
5.	The pneumonia shot is recommended for people 65 and over and for younger people with medical conditions such as heart disease and lung disease. This vaccine prevents complications and deaths from pneumonia. 
a.	Would you consider getting it? Why or why not?
6.	For those of you who have not had this shot, can you tell me why?
a.	Do you have specific reasons?
7.	What would make you more willing to get this shot?

APPENDIX D:
DISCUSSION GUIDE FOR PHYSICIAN INTERVIEWS

GUIDE FOR PHYSICIAN INTERVIEWS

Final Draft August 14, 2002

Purpose:  To gather qualitative information from physicians about practice behaviors and barriers (for example, financial, cultural, socioeconomic) that foster low influenza and pneumococcal immunization rates in African-American and Hispanic-American populations. Additionally, to test reactions to proposed messages, materials, and concepts for education/information campaigns that target providers and patients.

1.	What percentage of your patient base population is over 65? African American?  Hispanic American?  (fill in blank)
2.	How often do you screen the vaccination status of your patients?  (fill in blank)
3.	Do you maintain an immunization record in their charts? (fill in blank)
4.	What do you personally think about influenza and pneumococcal immunizations? (fill in blank)
5.	Do you actively recommend flu shots and pneumococcal immunizations for your healthy patients age 65 and older?  Why or why not? (fill in blank)
6.	Do you actively recommend flu shots and pneumococcal immunizations for your patients who have one or more risk factors? (fill in blank)
7.	What is your primary message to patients about the benefits of getting a flu shot? A pneumococcal vaccination? (fill in blank)
8.	How do you counsel patients about these benefits? How do you address their objections or concerns?  (fill in blank)
9.	What percentage of your patients over 65 request annual flu shots? What do you think motivates them to do so? (fill in blank)
10.	Can you tell me more about your patients who aren’t interested in getting a flu shot or decline a flu shot? What are their primary reasons?  (fill in blank)
11.	Are certain types of people not interested in getting a flu shot? Have you noticed any racial, ethnic, income, or gender differences associated with interest in getting a flu shot? (fill in blank)
12.	What kinds of barriers prevent your African-American patients from receiving an annual flu shot? Your Hispanic-American patients?  (fill in blank)
13.	What would you recommend to increase influenza immunization rates in these populations? (fill in blank)
14.	What barriers do you face when it comes to recommending or administering flu vaccine? (fill in blank)
15.	Are providers adequately reimbursed for administering influenza vaccine? (fill in blank)
16.	Do you think providers should receive financial incentives for supporting programs that have measurable outcomes? (that is, increasing immunization rates for influenza and pneumococcal immunizations) (fill in blank)
17.	Do you use a systematic method to ensure that your patients receive an annual flu shot? A pneumococcal vaccination? (fill in blank)
18.	Do you use a reminder recall system for flu shots? Why or why not? (fill in blank)
19.	Do you use standing orders? Why or why not? (fill in blank)
20.	Do you refer patients to pharmacy, grocery store, or other public health sponsored clinics? (fill in blank)
21.	How do you communicate important health care information to your patients? (fill in blank)
22.	What systems do you think are most effective in helping to identify patients who need to be vaccinated? (fill in blank)
23.	We know that physicians receive a lot of mail and promotional items from many sources. With that in mind, we are interested in learning what types of communication/education resources you and your patients value most. We are going to show you a variety of education/communication materials (SHOW POSTER, BROCHURE, POSTCARDS, AND PROMO ITEMS IN ROTATING ORDER) We would like your opinion on how they can be used effectively.

What is the most effective way of communicating important messages to physicians? (fill in blank)

Direct Mail Postcards/Reminder Recall

(SHOW THE POSTCARD CONCEPTS AND THE REMINDER RECALL CONCEPTS SIDE-BY-SIDE)

1.	Which of these concepts do you like best?  Why? (fill in blank)
2.	Which do you like least?  Why? (fill in blank)
3.	What is the primary message? (fill in blank)
4.	In your opinion, what information is most persuasive? What is least important?  (fill in blank)
5.	Are educational materials from C.D.C. considered a reliable and trusted source if information?  (fill in blank)

Posters/Brochures/Promotional Items
(SHOW POSTERS, BROCHURES, PROMOTIONAL ITEMS)

6.	Which of these concepts do you like best? Why? (fill in blank)
7.	Which do you like least? Why? (fill in blank)
8.	Would you take time to read a brochure that you received in the mail about the importance of influenza immunization? (fill in blank)
9.	Do you use posters and brochures in your office? If so, where are they likely to be found?  (fill in blank)
10.	Do you hand out educational materials when patients sign in or leave your office? (fill in blank)
11.	What types of materials do you prefer as teaching tools for your patients? (fill in blank)
12.	Do you use promotional items as “giveaway” reminders for your patients? If so, what do you prefer? (fill in blank)
13.	Do you use promotional items yourself? Why? Why not? (fill in blank)