SLV Community Health Survey (Version 10) 2010 · SLV Community Health Survey (Version 10) ... My...
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1 SLV Community Health Survey (Version 10) Last Updated: February 11, 2011 jep 2010 C mode: 1 In-Person 2 Telephone primary int: ___________ com ent 1: ________ com ent 2: ________ sec int: ____________ com ent date 1: ____/____/____ com ent date 2: ____/_____/____ SID:________________ Date: __________________ County: ______________ PSU ID ________________
Transcript of SLV Community Health Survey (Version 10) 2010 · SLV Community Health Survey (Version 10) ... My...
1
SLV Community Health Survey
(Version 10) Last Updated: February 11, 2011 jep
2010
C mode: 1 In-Person 2 Telephone
primary int: ___________ com ent 1: ________ com ent 2: ________ sec int: ____________ com ent date 1: ____/____/____ com ent date 2: ____/_____/____
SID:________________ Date: __________________
County: ______________ PSU ID ________________
2
Table of Contents Table of Contents .......................................................................................................................................... 2 Interviewer’s Script ........................................................................................................................................ 3 Core Sections
Section 1: Health Status ........................................................................................................................... 5 Section 2: Healthy Days — Health-Related Quality of Life ...................................................................... 5 Section 3: Health Care Access ................................................................................................................. 5 Section 4: Sleep ...................................................................................................................................... 11 Section 5: Physical Activity ..................................................................................................................... 12 Section 6: Television Use ....................................................................................................................... 15 Section 7: Diabetes ................................................................................................................................. 15 Section 8: Cardiovascular Disease ......................................................................................................... 18 Section 9: Hypertension.......................................................................................................................... 19 Section 10: Cholesterol........................................................................................................................... 19 Section 11: Asthma ................................................................................................................................. 20 Section 12: Arthritis ................................................................................................................................. 20 Section 13: Allergies ............................................................................................................................... 22 Section 14: Tobacco Use........................................................................................................................ 22 Section 15: Alcohol Consumption ........................................................................................................... 23 Section 16: Demographics...................................................................................................................... 24 Section 17: Fruits and Vegetables .......................................................................................................... 28 Section 18: Diet ...................................................................................................................................... 30 Section 19: Height & Weight ................................................................................................................... 31 Section 20: Weight Loss ......................................................................................................................... 32 Section 21: Oral Health........................................................................................................................... 34 Section 22: Seatbelt Use ........................................................................................................................ 34 Section 23: Women’s Health .................................................................................................................. 35 Section 24: Colorectal Screening……………………………………………………………………………...36 Section 25: Cancer Survivor ................................................................................................................... 36 Section 26: Anxiety & Depression .......................................................................................................... 37 Section 27: Emotional Support ............................................................................................................... 38 Section 28: Life Satisfaction ................................................................................................................... 38 Section 29: Spiritual Health .................................................................................................................... 38 Section 30: Preventive Counseling ......................................................................................................... 39 Section 31: Environment Assessment .................................................................................................... 40 Section 32: Personal Responsibility ....................................................................................................... 41 Section 33: Planning for the Future ........................................................................................................ 41 Section 34: Social Capital ....................................................................................................................... 42
Interviewer Perceptions ............................................................................................................................... 46
3
IF SOMEONE FROM A SELECTED HOUSEHOLD CALLS THE OFFICE AND NO ONE HAS BEEN RANDOMLY SELECTED -> COMPLETE THE ENUMERATION AND DEMOGRAPHICS SURVEY FIRST
FOR THOSE WHO HAVE ALREADY BEEN RANDOMLY SELECTED: Hello, my name is ___[Name]_______ . I’m with the San Luis Valley Community Health Survey. May I speak to [NAME OF PERSON RANDOMLY SELECTED AT THE TIME OF RECRUITMENT]? IF PERSON WHO ANSWERS ASKS ABOUT THE NATURE OF THE CALL, SAY THE FOLLOWING: We’re talking with 1,200 adults this year from across the Valley to get information about people’s health. One of our staff members visited your home and spoke with [INSERT NAME OF PERSON WHO RECEIVED GIFT CARD] about the survey. [INSERT NAME OF PERSON RANDOMLY SELECTED AT THE TIME OF RECRUITMENT] has been randomly selected to answer some questions. Is he/she available? [CONTINUE ONLY WITH PERSON WHO WAS RANDOMLY SELECTED TO PARTICIPATE]
WITH PERSON WHO IS RANDOMLY SELECTED: IF AT HOUSE:
Hi/Hello my name is [Name] . This is [NAME OF PARTNER]). We’re with the San Luis Valley Community Health Survey. You were randomly selected to participate in a health survey and we’re hoping you might be willing to answer some questions. You received a $10 gift card as an advanced thank you for doing the survey. The survey is voluntary and you do not have to answer any questions you don’t want to. It takes about 30-45 minutes. Your answers will be kept confidential and will not be connected with your name. Your answers will be grouped together with the answers of other people who complete the survey. There are no known risks or discomforts related to participating. If you have any questions about the survey, I can try to answer them or I have two phone numbers you can call to get answers to your questions. Does all this sound okay? Do you have any questions? IF ON PHONE: Hi/Hello my name is [Name] . I’m with the San Luis Valley Community Health Survey. [CL NAME] visited your house earlier and spoke with [YOU OR NAME OF FAMILY MEMBER]. We also left a $10 gift card as an advanced thank you for doing the survey. Does any of this sound familiar?
If it’s not familiar, say: OK. No problem. I can quickly tell you about it. We’re talking with 1,200 adults this year from across the Valley to get information about people’s health. This information will be very helpful to public health agencies and health care providers in the Valley for things like program planning and knowing what types of health care services are needed.
You were randomly selected to participate in this health survey and we’re hoping you might be willing to answer some questions. It’s voluntary and you do not have to answer any questions you don’t want to. The survey takes about 30-45 minutes. Your answers will be kept confidential and will not be connected with your name. Your answers will be grouped together with the answers of other people who complete the survey. There are no known risks or discomforts related to participating. If you have any questions
4
about the survey, I can try to answer them, or I have two phone numbers you can call to get answers to your questions. Does all this sound okay? Do you have any questions? My supervisors would like me to record my survey interview with you for quality control purposes. Is this okay with you?
1
Yes
0
No
[IF YES, TURN ON AUDIO RECORDING EQUIPMENT. IF NO, DO NOT TURN ON EQUIPMENT AND ASSURE RESPONDENT THAT THIS IS FINE.] [IF THERE ARE QUESTIONS YOU CAN’T ANSWER, READ THE FOLLOWING] Here are two phone numbers. The first one is for the Principal Investigator of the study (Elaine Belansky, 303-724-4383) and the next one is for the Colorado Multiple Institutional Review Board. This is the Board that oversees all research at the University of Colorado Denver (303-724-1055). [NOTE TO INTERVIEWER: PLEASE INDICATE RESPONDENT’S GENDER] a. Respondent’s Gender:
1
Male
0
Female
[IF GENDER IF UNCLEAR, ASK “WHAT IS YOUR GENDER?” AND MARK APPROPRIATE RESPONSE]
5
Section 1: Health Status Let's get started. The first set of questions is about your health in general.
Excellent Very Good Good Fair Poor D/K Ref.
1. In general, would you say your health is:
[READ RESPONSE LIST]
[s1q1]
5
4
3
2
1
-1
-2
Section 2: Healthy Days — Health-Related Quality of Life
RECORD # OF DAYS D/K Ref.
2. Now thinking about your physical health, which includes physical illness and injury, how many days during the past 30 days was your physical health not good?
[s2q2]
_________
-1
-2
3. Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?
[If Q2 & Q3 = None, go to Next Section]
[s2q3]
_________
-1
-2
4. During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation?
[s2q4]
_________
-1
-2
Section 3: Health Care Access The next few questions that I will ask you will be about your health care access to health care services.
Yes No D/K Ref.
5. Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMO's, or government plans such as Medicare?
[s3q5]
1
0
Skip to Q8
-1
Skip to Q19
-2
Skip to Q19
6
6. I am going to read you a list of different types of health
insurance coverage. Please tell me if you currently have any of the following types of insurance. Please do not include any health insurance plans that cover only ONE type of service, like plans for dental care or prescription drugs.
Do you currently have……[READ LIST]?
Yes No D/K Ref.
a. Health insurance through your work or union [PROBE: This insurance could be through COBRA, through a former employer or a retiree benefit.] [s3q6a]
1
0
-1
-2
b. Health insurance through someone else’s work or union [PROBE: This insurance could be through COBRA, through a former employer or a retiree benefit.] [s3q6b]
1
0
-1
-2
c. Medicare [PROBE: Medicare is the health insurance for persons 65 years old and older or persons with disabilities. This is a red, white and blue card and includes Medicare parts A, B, C or D] [s3q6c]
1
0
-1
-2
d. Railroad Retirement Plan [s3q6d]
1
0
-1
-2
e. Veteran’s Affairs, Military Health, TRICARE or CHAMPUS [s3q6e]
1
0
-1
-2
f. The Indian Health Service [s3q6f]
1
0
-1
-2
g. Medicaid [PROBE: This is a Colorado program for low-income families with children, seniors, and people with disabilities.] [s3q6g]
1
0
-1
-2
h. Child Health Plan Plus (CHP+ [Chip Plus]). [PROBE:
This is a Colorado Program for low and moderate income children under age 19 and pregnant women who live in families that earn more than is allowed to be on Medicaid.] [IF RESPONDENT/TARGET ANSWERS “YES” AND RESPONDENT/TARGET IS FEMALE 19 YEARS OR OLDER, ASK “Again, CHP+ is a Colorado program for low and moderate income children under age 19 and pregnant women who live in families that earn more than is allowed under Medicaid. Do you fall into one of these two groups?” [s3q6h]
1
0
-1
-2
i. Student health plan [PROBE: This is a health insurance plan that is sponsored by a college or university.] [s3q6i]
1
0
-1
-2
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Yes No D/K Ref.
j. Health insurance bought directly by you [PROBE: For example, bought directly from Anthem, Kaiser, United or another company or bought through an insurance broker.] [s3q6j]
1
0
-1
-2
k. Health insurance bought directly by someone else [s3q6k]
1
0
-1
-2
Do you currently have any other type of insurance? [DO NOT READ, ALLOW MULTIPLE]
l Workers compensation for specific injury/illness
[s3q6l]
m Employer pays for bills, but not an insurance policy
[s3q6m]
n Family member pays out of pocket for any bills
[s3q6n]
o Other non insurance payment source like a discount card
(SPECIFY) _________________ (e.g., CHC/CICP) [s3q6o]
p Other insurance (SPECIFY) ________________________________
[s3q6p]
For the purposes of this survey, we’ll assume that you do not have health insurance. -
> [SKIP TO Q9]
-1
-2
7. Have you had insurance coverage for all of the past 12 months?
[s3q7]
1
Yes
Skip to Q19
0
No
-1
Skip to Q9
-2
Skip to Q9
8. How many months in the past 12 months have you been without health insurance coverage?
_____________ # of Months [s3q8]
-1
-2
Skip to Q9 Read Script Belo
w
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I’m going to read a list of reasons that people sometimes give for why they don’t have health insurance. Please tell me if these are reasons that you have not had health insurance. How about…
Yes No D/K Ref.
9. The person in family who had health insurance lost job or changed employers? [s3q9]
1
0
-1
-2
10. The person in family who had health insurance is no longer part of the family because of divorce, separation or death?
[s3q10]
1
0
-1
-2
11. Family member’s employer does not offer coverage or not eligible for employer’s coverage? [s3q11]
1
0
-1
-2
12. Lost eligibility for Medicaid or the Child Health Plan Plus (CHP+)?
[s3q12]
1
0
-1
-2
13. Cost is too high? [s3q13]
1
0
-1
-2
14. Don’t need insurance? [s3q14]
1
0
-1
-2
15. Don’t know how to get insurance? [s3q15]
1
0
-1
-2
16. Traded health insurance for another benefit or higher pay? [s3q16]
1
0
-1
-2
17. Can’t get health insurance, have pre-existing condition? [s3q17]
1
0
-1
-2
18. Some other reason? [SPECIFY] ________________ [s3q18]
1
0
-1
-2
[ASK EVERYONE]
19. Do you have any kind of insurance coverage that pays for some or all of your routine dental care, including dental insurance, prepaid plans such as Delta Dental or government plans such as Medicaid? [s3q19]
1
0
-1
-2
Now I’m going to ask you some questions about the health care you get.
9
D/K Ref.
20. Do you have one person you think of as your personal doctor or health care provider? [s3q20]
IF “NO,” ASK: “Is there more than one, or is there no person who you think of as your personal doctor or health care provider?”
1
Yes
Skip to Q22
2
Yes, more than one
Skip to
Q22
0
No
-1
Skip to Q22
-2
Skip to Q22
21. What are the main reasons you do NOT have a personal doctor or health care provider that you go for health care? [DO NOT READ LIST; CHECK ALL THAT APPLY] CHECK = 1 NO CHECK = 0
1 Can’t afford it. [s3q21_1]
2 Do not have health insurance [s3q21_2]
3 Rarely get sick [s3q21_3]
4 Clinic hours don’t fit my schedule [s3q21_4]
5 Transportation difficulties – general [s3q21_5]
6 Transportation difficulties – live in rural area and it’s too far
[s3q21_6] 7 Transportation difficulties – live in rural area and public
transportation is difficult [s3q21_7] 8 Language is a barrier [s3q21_8]
9 Do not like/trust/believe in doctors [s3q21_9]
10 Clinic I used to go to closed [s3q21_10]
11 Just moved, do not have a regular place yet [s3q21_11]
12 Two or more places depending on what’s wrong [s3q21_12]
13 Use the emergency room primarily [s3q21_13]
14 Other [SPECIFY] __________________________
[s3q21_14]
-1
-2
22. Was there a time in the past 12 months when you needed to see a doctor but could not because of cost? [s3q22]
1
Yes
0
No
-1
-2
23. About how long has it been since you last visited a doctor for a routine checkup? [READ RESPONSE OPTIONS] [s3q23]
1
Within the last year (1
to 12 months
ago)
2
1 to 2 years ago
3
2-5 years ago
4
5 or more years ago
-1
-2
10
D/K Ref.
24. In the past 12 months, how many times did you receive care in a hospital emergency room? [READ LIST IF NECESSARY. MARK ONLY ONE]
[s3q24]
0
None
Skip to 29
1
1 time
2
2 times
3
3 times
4
More than 3 times
-1
Skip to Q29
-2
Skip to Q29
I’m going to read a list of reasons why some people go to the emergency room. Please tell me if these were important reasons for your last visit to a hospital emergency room. Was this an important reason…
Next, I’m going to read you a list of problems some people experience when they try to get health care. Please tell me if you have had these problems in the past 12 months.
Yes No D/K Ref.
29. You were unable to get an appointment at the doctor’s office or clinic as soon as you thought one was needed? [s3q29]
1
0
-1
-2
30. You were told by a doctor's office or clinic that they weren't accepting patients with your type of health insurance? [s3q30]
1
0
-1
-2
31. You were told by a doctor's office or clinic that they weren't accepting new patients? [s3q31]
1
0
-1
-2
Yes No D/K Ref.
25. You were unable to get an appointment at the doctor’s office or clinic as soon as you thought was needed? [s3q25]
1
0
-1
-2
26. You needed care after normal operating hours at the doctor’s office or clinic? [s3q26]
1
0
-1
-2
27. You owed money to the doctor’s office or clinic? [s3q27]
1
0
-1
-2
28. It was more convenient to go to the hospital emergency room? [s3q28]
1
0
-1
-2
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My next questions are about the health care costs that you and your immediate family had in the past 12 months. First, I'd like to ask about how much was spent "out of pocket" for health care in the past 12 months for you and your immediate family. "Out of pocket" is the amount of money you pay that is not covered by any insurance or special assistance that you might have. It does not include any premiums that you pay for your health insurance or any health care costs that will be reimbursed. Please include co-pays in your estimate.
D/K Ref.
32. How much was spent "out of pocket" for health care in the past 12 months for you and your immediate family? [PROBE: Your best estimate is fine. Read response options, if necessary.]
1 $0 (zero) [PROBE: did not have any “out of
pocket” health care expenses] 2 $1 to under $200
3 $200 to under $500
4 $500 to under $1,000
5 $1,000 to under $3,000
6 $3,000 to under $5,000
7 $5,000 or more
[s3q32]
-1
-2
Section 4: Sleep Now we are going to shift gears and ask you about sleep and exercise.
[RECORD] D/K Ref.
33. During the past 30 days, for about how many days have you felt you did not get enough rest or sleep?
[s4q33]
_________ Days
-1
-2
12
Section 5: Physical Activity Now we’ll talk about physical activity. First I’m going to ask about physical activity you get at work, if you do work; then I’m going to ask you about physical activity you get outside of work. Before I get to the physical activity questions I need to ask about your work situation.
D/K Ref.
34. Are you currently: [READ ALL RESPONSE OPTIONS; IF MORE THAN ONE, RECORD THE ONE THAT RESPONDENT MOST IDENTIFIES WITH (E.G., SPENDS THE MOST TIME DOING)]
1 Employed for wages -> GO TO NEXT QUESTION
2 Self-employed -> GO TO NEXT QUESTION
3 Out of work for more than 1 year -> SKIP TO Q36
4 Out of work for less than 1 year -> SKIP TO Q36
5 Homemaker -> SKIP TO Q36
6 Student -> SKIP TO Q36
7 Retired -> SKIP TO Q36
8 Unable to work -> SKIP TO Q36
[s5q34]
-1
Skip to Q36
-2
Skip to Q36
35. When you are at work, which of the following best describes what you do? Would you say….[READ ALL RESPONSE OPTIONS]
[s5q35]
Note: If respondent has multiple jobs, ask to think about all jobs, but to focus on what he/she “mostly” does.
1
Mostly sitting or standing
2
Mostly walking
3
Mostly heavy labor
or physically
demanding work
-1
-2
Now let’s talk about physical activity you get outside of work. We are interested in two types of physical activity – vigorous and moderate. First, let’s start with moderate activities. Those are the ones that cause small increases in breathing or heart rate.
D/K Ref.
36. In a usual week, do you walk for at least 10
minutes at a time for recreation, exercise, to get to and from places, or for any other reason?
[s5q36]
1
Yes
0
No
Skip to Q38
-1
Skip to Q38
-2
Skip to Q38
37. How many days per week do you do these activities?
__________ # of Days [s5q37]
-1
-2
13
D/K Ref.
37a. On days when you walked for at least 10 minutes at a time, how much total time did you spend walking?
_______ Hours/day and/or ________ Minutes/day
[s5q37a]
-1
-2
38. Now, thinking about the moderate activities you do [fill in “when you are not working” if employed or self-employed] in a usual week, do you do moderate activities for at least 10 minutes at a time, such as brisk walking, bicycling, vacuuming, gardening, or anything else that causes small increases in breathing or heart rate?
[s5q38]
1
Yes
0
No
Skip to Q41
-1
Skip to Q41
-2
Skip to Q 41
39. How many days per week do you do these moderate activities for at least 10 minutes at a time?
________ Days [RECORD]
[s5q39]
-1
Skip to Q41
-2
Skip to Q41
40. On days when you do moderate activities for at least 10 minutes at a time, how much total time per day do you spend doing these activities?
_______ Hours/day and/or ______ Minutes/day [RECORD]
[s5q40]
-1
-2
Now let’s talk about vigorous activities. These are the ones that cause large increases in breathing or heart rate.
D/K Ref.
41. Now, thinking about the vigorous activities you do [fill in “when you are not working” if employed or self-employed] in a usual week, do you do vigorous activities for at least 10 minutes at a time, such as running, aerobics, heavy yard work, or anything else that causes large increases in breathing or heart rate?
[s5q41]
1
Yes
0
No
Skip to Q45, unless Q38 =1, DK or R, then go to Q44
-1
Skip to Q45,
unless Q38 =1, DK or R, then go to Q44
-2
Skip to Q45,
unless Q38 =1, DK or R, then go to Q44
42. How many days per week do you do these vigorous activities for at least 10 minutes at a time?
________ Days [RECORD # OF DAYS PER WEEK]
[s5q42]
-1
Skip to Q44
-2
Skip to Q44
14
DK Ref.
43. On days when you do vigorous activities for at least 10 minutes at a time, how much total time per day do you spend doing these activities?
_______ Hours/day and/or ______ Minutes/day [s5q43]
-1
-2
44. I’m going to read you a list of activities. Thinking about the moderate or vigorous physical activity you did in the past month, what did you spend time doing? [READ LIST, CHECK ALL THAT APPLY]
a Walking [s5q44a]
b Running [s5q44b]
c Bicycling [s5q44c]
d Swimming [s5q44d]
e Housework [s5q44e]
f Laboring (lifting, building, etc.) [s5q44f]
g Exercising using weights [s5q44g]
h Exercising using cardio equipment (Stairmaster,
rowing machine, etc.) [s5q44h]
i Dancing [s5q44i]
j Aerobics (step or floor) [s5q44j]
k Racquetball/Tennis/Handball [s5q44k]
l Other (SPECIFY) __________________ [s5q44l]
m None/no activities [s5q44m]
-1
-2
45. On a typical weekday, how much time do you spend in a car? [DON’T RECORD A RANGE] _______ Hours/day and/or ______ Minutes/day [s5q45]
-1
-2
46. According to the latest national recommendations, how many minutes of moderate physical activity, such as walking, yard work, biking, or housecleaning are adults suppose to get every week?
[DON’T RECORD A RANGE] ________ Minutes per week [s5q46]
-1
-2
15
Section 6: Television Use The next few questions are about your television use.
D/K Ref.
47. How many working television sets do you have in your home?
[s6q47]
_________ # of Television Sets [RECORD]
[IF “0” -> SKIP TO Q49]
-1
-2
48. Do you have a television set in the room where you sleep?
[s6q48]
1
Yes
0
No
-1
-2
49. How much time do you usually spend on a typical weekday watching TV, videos, DVDs, or playing computer/video games?
Note: This does not include active video games, such as the Wii Fit.
[s6q49]
0
None
1
Less than 1 hour
2
1-2 hours
3
3-4 hours
4
5 hours or more
-1
-2
Section 7: Diabetes Now I’m going to ask you about different kinds of health issues. We’ll start with diabetes.
D/K Ref.
50. Have you ever been told by a doctor that you have diabetes?
Note: If “Yes” and respondent is female, ask: “Was this only when you were pregnant?” [s7q50]
1
Yes
2
Yes, but female told only during pregnancy
3
No
Skip to Section
8
4
No, pre-diabetes or borderline diabetes
Skip to Section 8
-1
Skip to Section
8
-2
Skip to Section
8
51. How old were you when you were told you have diabetes?
[s7q51]
________ years old [RECORD]
-1
-2
16
D/K Ref.
52. About how often do you check your blood for glucose or sugar?
Note: If response is 6 or more times per day or 36 or more times per week, verify answer with respondent. [s7q52]
1
_____
Times per day
[s7q52d]
2
_____
Times per week
[s7q52w]
3
_____
Times per
month
[s7q52m]
4
______
Times per year
[s7q52y]
0
Never
Skip to Q54
-1
Skip to Q54
-2
Skip to Q54
53. How do you pay for checking your blood for glucose or sugar?
1 Private Insurance -> SKIP TO Q55
2 Medicaid -> SKIP TO Q55
3 Medicare -> SKIP TO Q55
4 Out of pocket -> SKIP TO Q55
5 Other – [Specify] ______________->SKIP TO Q55
[s7q53]
-1
Skip to Q55
-2
Skip to Q55
17
D/K Ref.
54. Why don't you check your blood for glucose or sugar?
[DO NOT READ RESPONSES. CHECK ALL THAT APPLY.]
1 It was not recommended by my physician
2 My doctor checks it for me
3 It's not covered by my health care plan
4 It's too expensive
5 Don't know how
6 Don't like to do it
7 Don't think it's important/useful
8 No reason, I just don't do it
9 Other – [Specify]___________________ [s7q54]
-1
-2
55. When was the last time you took a course or class in how to manage your diabetes yourself? [DON’T READ RESPONSES]
1 Less than 6 months ago
2 6 months to less than one year
3 1 to less than 2 years
4 2 or more years ago
0 Never
[s7q55]
-1
-2
56. Have you ever had individualized education in how to manage your
diabetes yourself? 1 Yes
0 No
Note: This includes only one-on-one educational sessions. [s7q56]
-1
-2
57. Have you ever attended a San Luis Valley Diabetes Association support group meeting?
1 Yes
0 No
[s7q57]
-1
-2
18
D/K Ref.
58. Have you ever had an individual consultation from a pharmacist regarding your medications for diabetes?
1 Yes
0 No
[s7q58]
-1
-2
59. Where else have you obtained information about diabetes? (Other than these things we've just discussed) [DO NOT READ LIST, CHECK ALL THAT APPLY] CHECK = YES NO CHECK = NO
a Nurse or nurse practitioner [s7q59a]
b Dietician or Nutritionist [s7q59b]
c Diabetes educator [s7q59c]
d Doctor [s7q59d]
e Health department [s7q59e]
f Hospital [s7q59f]
g Newspaper or magazines [s7q59g]
h Television [s7q59h]
i Radio [s7q59i]
j Internet [s7q59j]
k Senior Center [s7q59k]
l Relative or friend [s7q59l]
m Diabetes Association [s7q59m]
n Library [s7q59n]
o School [s7q59o]
p Nutrition or Cooking Class [s7q59p]
q Support Group [s7q59q]
r Nowhere [s7q5r]
-1
-2
Section 8: Cardiovascular Disease
Now I would like to ask you some questions about cardiovascular disease, hypertension and cholesterol. Has a health care provider EVER told you that you had any of the following? For each, tell me “Yes” or “No.”
Has a doctor, nurse or other heath professional ever told you that....
Yes No D/K Ref.
60. you had a heart attack, also called a myocardial infarction?
[s8q60]
1
0
-1
-2
61. you had angina or coronary heart disease?
[s8q61]
1
0
-1
-2
19
Has a doctor, nurse or other heath professional ever told you that....
Yes No D/K Ref.
62. you had a stroke?
[s8q62]
1
0
-1
-2
Section 9: Hypertension
D/K Ref.
63. Have you ever been told by a doctor, nurse or other health provider that you have high blood pressure?
Note: If “Yes” and respondent is female, ask: “Was this only when you were pregnant?” [s9q63]
1
Yes
2
Yes, but female told only during pregnancy
Skip to Section 10
3
No
Skip to Section
10
4
No, pre-hypertensive or borderline high
Skip to Section 10
-1
Skip to Section
10
-2
Skip to Section
10
64. Are you currently taking medicine for your high blood pressure?
[s9q64]
1
Yes
0
No
-1
-2
Section 10: Cholesterol
DK Ref.
65. Blood cholesterol is a fatty substance found in the blood. Have you ever had your blood cholesterol checked?
1 Yes -> GO TO NEXT QUESTION
0 No –>SKIP TO SECTION 11
[s10q65]
-1
Skip to Section
11
-2
Skip to Section 11
66. About how long has it been since you last had your blood cholesterol checked?
1 Within the past year (1 to 12 months ago)
2 1 to 2 years ago
3 2 to 5 years ago
4 5 or more years ago
[s10q66]
-1
-2
20
D/K Ref.
67. Have you ever been told by a health care provider that your blood cholesterol is high?
1 Yes -> GO TO NEXT QUESTION
0 No –> SKIP TO SECTION 11 [s10q67]
-1
Skip to Section
11
-2
Skip to Section 11
68. Are you now taking any medication prescribed by a doctor to lower your blood cholesterol?
1 Yes
0 No
[s10q68]
-1
-2
Section 11: Asthma
Now I’ll ask you about asthma.
Yes No D/K Ref.
69. Have you ever been told by a health care provider that you have asthma?
[s11q69]
1
0
Skip to Section 12
-1
Skip to Section 12
-2
Skip to Section 12
70. Do you still have asthma?
[s11q70]
1
0
-1
-2
Section 12: Arthritis
Next I will ask you about arthritis.
Yes No D/K Ref.
71. Have you EVER been told by a doctor or other health care professional that you have some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?
INTERVIEWER NOTE: Arthritis diagnoses include:
rheumatism, polymyalgia rheumatica, osteoarthritis (not osteoporosis) tendonitis, bursitis, bunion, tennis elbow carpal tunnel syndrome, tarsal tunnel
syndrome joint infection, Reiter’s syndrome ankylosing spondylitis; spondylosis rotator cuff syndrome connective tissue disease, scleroderma,
polymyositis, Raynaud’s syndrome vasculitis (giant cell arteritis, Henoch-
Schonlein purpura, Wegener’s granulomatosis, polyarteritis nodosa)
[s12q71]
1
0
-1
-2
21
Yes No D/K Ref.
72. Arthritis can cause symptoms like pain, aching, or stiffness in or around the joint. During the past 30 days, have you had any symptoms of pain, aching, or stiffness in or around a joint?
INTERVIEWER INSTRUCTION: If a question arises about medications or treatment, then the interviewer should say: “Please answer the question based on your current experience, regardless of whether you are taking any medication or treatment.”
[s12q72]
1
0
Skip to Section 13
-1
Skip to Section 13
-2
Skip to Section 13
***[ASK ONLY IF RESPONDENT IS EMPLOYED OR SELF-EMPLOYED – Q34]***
73. In this next question, we are referring to work for pay. Do arthritis or joint symptoms now affect whether you work, the type of work you do, or the amount of work you do?
1 Yes
0 No
INTERVIEWER INSTRUCTION: If respondent gives an answer to each issue (whether works, type work, or amount of work), then if any issue is “yes” mark the overall response as “yes.” If a question arises about medications or treatment, then the interviewer should say: “Please answer the question based on your current experience, regardless of whether you are taking any medication or treatment.”
[s12q73]
-1
-2
74. During the past 30 days, to what extent has your arthritis or joint symptoms interfered with your normal social activities, such as going shopping, to the movies, or to religious or social gatherings? [READ RESPONSES]
2 A lot
1 A little
0 Not at all
INTERVIEWER INSTRUCTION: If a question arises about medications or treatment, then the interviewer should say: “Please answer the question based on your current experience, regardless of whether you are taking any medication or treatment.”
[s12q74]
-1
-2
22
D/K Ref.
75. Please think about the past 30 days, keeping in mind all of your joint pain or aching, whether or not you have taken medication. DURING THE PAST 30 DAYS, how bad was your joint pain ON AVERAGE? Please answer on a scale of 0 to 10 where 0 is no pain or aching and 10 is pain or aching as bad as it can be.
__________ ENTER # [RECORD A WHOLE NUMBER] [s12q75]
-1
-2
Section 13: Allergies
Now, I’ll ask you one question about allergies.
Yes No D/K Ref.
76. During the past 30 days, have you had any allergy symptoms, including itchy or watery eyes, congestion, or a rash?
[s13q76]
1
0
-1
-2
Section 14: Tobacco Use
Next, we are moving on to questions about tobacco use.
D/K Ref.
77. Have you smoked at least 100 cigarettes in your entire life?
[s14q77]
1
Yes
0
No
Skip to Q81
-1
Skip to Q81
-2
Skip to Q81
78. Do you now smoke cigarettes every day, some days, or not at all? 2 Every day
1 Some days
0 Not at all -> SKIP TO Q80
[s14q78]
-1
Skip to Q81
-2
Skip to Q81
23
D/K Ref.
79. During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking?
1 Yes -> SKIP TO Q81
0 No -> SKIP TO Q81
[s14q79]
-1
Skip to Q81
-2
Skip to Q81
80. How long has it been since you last smoked cigarettes regularly? [DON’T READ RESPONSE OPTIONS] [IF ASKED: Regularly is at least a few cigarettes every few days. A few days means at least every 2 or 3 days.]
1 Within the past month (less than one month ago)
[s14q80-1]
2 1-2 months ago
3 3-5 months ago
4 6-11 months
5 1-4 years ago
6 5-9 years ago
7 10 years or more
0 Never smoked regularly
[s14q80]
-1
-2
81. Do you currently use chewing tobacco, snuff, or snus [pronounced snoose] every day, some days, or not at all?
2 Every day
1 Some days
0 Not at all [s14q81]
-1
-2
Section 15: Alcohol Consumption
Now, I’ll ask you a few questions about alcohol use.
D/K Ref.
82. During the past 30 days, have you had at least one drink of any alcoholic beverage such as beer, wine, a malt beverage or liquor?
[s15q82]
1
Yes
0
No
Skip to Section 16
-1
Skip to Section 16
-2
Skip to Section 16
24
D/K Ref.
83. During the past 30 days, how many days per week or per month did you have at least one drink of any alcoholic beverage?
____ Days per week [s15q83w]
____ Days in past month [s15q83m]
-1
-2
84. One drink is equivalent to a 12 ounce beer, a 5 ounce glass of wine, or a drink with one shot of liquor. During the past 30 days, on the days when you drank, about how many drinks did you drink on the average?
Note: A 40 ounce beer would count as 3 drinks, or a cocktail drink with 2 shots would count as 2 drinks.
_____ # of Drinks [s15q84]
-1
-2
85. Considering all types of alcoholic beverages, how many times during the past 30 days did you have [5 for men]/ [ 4 for women] or more drinks on any occasion?
_____ # of Times [s15q85]
-1
-2
86. During the past 30 days, what is the largest number of drinks you had on any occasion?
_____ # of Drinks [s15q86]
-1
-2
87. During the past 30 days, how many times have you driven when you've had perhaps too much to drink?
_____ # of Times
[s15q87]
-1
-2
Section 16: Demographics
I am going to take a quick break from the types of questions that I have been asking you and ask you more specific questions about you and your family.
D/K Ref.
88. Are you Hispanic or Latino?
[s16q88]
1
Yes
0
No
-1
-2
25
D/K Ref.
89. Which one or more of the following would you say is your race? [READ RESPONSES]
1 White
2 Black or African American
3 Asian
4 Native Hawaiian or Other Pacific Islander
5 American Indian or Alaska Native
6 Other _______________________[Specify]
NOTE: IF MORE THAN ONE RESPONSE, ASK NEXT QUESTION; OTHERWISE, SKIP
TO Q91. [s16q89]
-1
-2
90. Which one of these groups would you say best represents your race? [READ RESPONSES]
1 White
2 Black or African American
3 Asian
4 Native Hawaiian or Other Pacific Islander
5 American Indian or Alaska Native
6 Other __________________[Specify] [s16q90]
-1
-2
91. How many children less than 18 years of age live in your household?
____________Number of children
[NOTE: IF MORE THAN 0, ASK NEXT QUESTION; OTHERWISE, SKIP TO Q93.] [s16q91]
-1
-2
92. How many children live in your house who are….
1. Less than 5 years old (early childhood) ______?
[s16q92-1]
2. 5 through 11 years old (elementary school) _____?
[s16q92-2]
3. 12 through 13 years old (middle school) ____?
[s16q92-3]
4. 14 through 17 years old (high school) _____?
[s16q92-4]
-1
-2
26
D/K Ref.
93. Are you…? [ONLY MARK ONE] 1 Married
2 Divorced
3 Widowed
4 Separated
5 Never Married
6 A member of an unmarried couple
[s16q93]
-1
-2
94. What is the highest grade or year of school you completed? [READ ONLY IF NECCESSARY]
0 Never attended school or only attended kindergarten
1 Grades 1 through 8 (Elementary)
2 Grades 9 through 11 (Some high school)
3 Grade 12 (High school graduate)
4 College 1 year to 3 years (some college or technical
school) 5 College 4 years or more (college graduate)
[s16q94]
-1
-2
95. What is your age? _______________ (Years) [s16q95]
-1
-2
96. Is your annual household income from all sources… 0 4 Less than $25,000 If “no,” ask 05; if “yes,” ask 03 ($20,000 to less than $25,000) 0 3 Less than $20,000 If “no,” code 04; if “yes,” ask 02 ($15,000 to less than $20,000) 0 2 Less than $15,000 If “no,” code 03; if “yes,” ask 01 ($10,000 to less than $15,000) 0 1 Less than $10,000 If “no,” code 02 0 5 Less than $35,000 If “no,” ask 06 ($25,000 to less than $35,000) 0 6 Less than $50,000 If “no,” ask 07 ($35,000 to less than $50,000) 0 7 Less than $75,000 If “no,” code 08 ($50,000 to less than $75,000) 0 8 $75,000 or more
-1
-2
27
[RECORD ANSWER BELOW]
1 Less than $10,000
2 $10,000 to less than $15,000
3 $15,000to less than $20,000
4 $20,000 to less than $25,000
5 $25,000 to less than $35,000
6 $35,000 to less than $50,000
7 $50,000 to less than $75,000
8 $75,000 or more
[s16q96]
97. How true is the following statement?...You relied on only a few kinds of low-cost food to feed your family because you were running out of money to buy food in the last 12 months. [READ RESPONSES]
2 Often True
1 Sometimes True
0 Never True
[s16q97]
-1
-2
The folks at 911, the Emergency Response Team, would like to update their records so that they can contact people in case of an emergency.
D/K Ref.
98. Do you have both types of telephones, a cellular telephone and a land line telephone? READ ONLY IF NECESSARY: “By cell telephone we mean a telephone that is mobile and usable outside of your neighborhood. By land line, we mean a telephone line that is in your house and only works inside your home.” [s16q98]
1
Yes, Both
2
No, Cell Only
Skip to 102
3
No,
Land Line Only
Skip to 100
-1
Skip to 100
-2
Skip to 100
99. Which is the best to reach you on?
[s16q99]
1
Cell
2
Land
Line
3
Both
-1
-2
28
D/K Ref.
100. Not including cell phones, have you or your family been without telephone service for one week or more DURING THE PAST 12 MONTHS? Do not include interruptions of phone service due to weather or natural disasters. [s16q100]
1
Yes
0
No
Skip to 102
-1
Skip to 102
-2
Skip to 102
101. Not including cell phones, how long were you or your family without telephone services in the PAST 12 MONTHS?
[s16q101]
1
< than 1 week
2
Day(s)
3
Months(s)
-1
-2
102. How many working cell phones do you or people in your family have?
[s16q102]
______
[RECORD]
-1
-2
Section 17: Fruits and Vegetables
These next questions are about the foods you usually eat or drink. Please tell me how often you eat or drink each one, for example, twice a week, three times a month, and so forth. Remember, I am only interested in the foods you eat. Include all foods you eat, both at home and away from home.
[DON’T READ RESPONSES; RECORD NUMBER ON LINE PROVIDED.]
D/K Ref.
103. How often do you drink fruit juices such as orange, grapefruit, or tomato? Number of times: [s17q103]
1
Per day
2
Per week
3
Per month
4
Per year
0
Never
-1
-2
104. Not counting juice, how often do you eat fruit?
Number of times: [s17q104]
1
Per day
2
Per week
3
Per month
4
Per year
0
Never
-1
-2
105. How often do you eat green salad? Number of times: [s17q105]
1
Per day
2
Per week
3
Per month
4
Per year
0
Never
-1
-2
29
D/K Ref.
106. How often do you eat potatoes not including French fries, fried potatoes, or potato chips? Number of times: [s17q106]
1
Per day
2
Per week
3
Per month
4
Per year
0
Never
-1
-2
107. How often do you eat carrots?
Number of times: [s17q107]
1
Per day
2
Per week
3
Per month
4
Per year
0
Never
-1
-2
108. Not counting carrots, potatoes, or salad, how many servings of vegetables do you usually eat? (Example: A serving of vegetables at both lunch and dinner would be two servings.)
Number of times: [s17q108]
1
Per day
2
Per week
3
Per month
4
Per year
0
Never
-1
-2
109. When you estimated the number of servings of vegetables that you usually eat, did you include dried peas or beans, that is such things as lentils, pinto beans, navy beans, or beans in chili or soup? [s17q109]
1
Yes
0
No
-1
-2
110. How often do you eat dried peas or beans, that is such things as lentils, pinto beans, navy beans, or beans in chili?
Number of times:
[s17q110]
1
Per day
2
Per week
3
Per month
4
Per year
0
Never
-1
-2
The next question is related to your confidence in eating more fruits and vegetables. Please answer, “Not very confident,” “Somewhat confident” or “Very confident”.
Not very confident
Somewhat confident
Very confident
D/K Ref.
111. If you wanted to eat more fruits and vegetables, how confident are you that you could do it? [s17q111]
1
2
3
-1
-2
30
D/K Ref.
112. According to the latest national recommendations, how many servings of fruits and vegetables should you eat each day? [s17q112]
________ [RECORD # - DON’T RECORD A RANGE]
-1
-2
Section 18: Diet
Now, I'm going to ask you about some of your food choices over the past four weeks. First, I'd like to ask about foods you ate at breakfast.
Always Often Sometimes Rarely Never D/K Ref.
113. In the past four weeks, how often did you have breakfast? [s18q113]
4
3
2
1
0
Skip to
Q117
-1
Skip to
Q117
-2
Skip to
Q117
114. When you ate breakfast, how often did you have 100% fruit juice? [s18q114]
4
3
2
1
0
-1
-2
115. When you ate breakfast, how often did you have a piece or serving of fruit [s18q115]
4
3
2
1
0
-1
-2
116. When you ate breakfast, how often did you have a serving of vegetables or a dish that had vegetables in it? [s18q116]
4
3
2
1
0
-1
-2
117. In the past four weeks, how often did you eat in between meals? [s18q117]
4
3
2
1
0
Skip to
Q121
-1
Skip to
Q121
-2
Skip to
Q121
118. When you ate in between meals, how often did you eat raw vegetables such as carrot sticks or celery? [s18q118]
4
3
2
1
0
-1
-2
119. When you ate in between meals, how often did you eat a piece or serving of fruit? [s18q119]
4
3
2
1
0
-1
-2
Always Often Sometimes Rarely Never D/K Ref.
31
120. When you ate in between meals, how often did you eat potato chips, cookies, or other high fat snack foods? [s18q120]
4
Always
3
Often
2
Sometimes
1
Rarely
0
Never
-1
-2
121. On a typical day, how many glasses or cans of regular soda pop or other sweetened drinks, such as fruit punch or sports drinks do you drink? Do NOT count diet drinks. (Includes any drinks with added sugar such as Cola, sunny delight, iced tea, lemonade, Hawaiian punch, Hi-C, Snapple, Gatorade, Kool-Aid.) [s18q121]
[Interviewer, ask respondent to estimate number of 8 oz glasses if drinking from a large bottle, tall can or carton.]
___________ glasses or cans
-1
-2
122. Now think about the past WEEK. In the past 7 days, how many times did you eat fast food? Include fast food meals eaten at school or at home, or at fast food restaurants, carryout or drive thru.
[Interviewer Note: A fast food restaurant is defined as a restaurant where you pay for your food at a counter or drive thru, before you eat it. If needed say, “Such as food you get at a McDonald’s, KFC, Panda Express, Taco Bell, Chipotle.”] [s18q122]
________# of times in past 7 days
-1
-2
123. During the past 7 days, how many times did all, or most of your family living in your house, eat a meal together? [DO NOT READ
LIST] [s18q123]
Not Applicable – Living alone
0
Never
1
1-2 times
2
3-4 times
3
5-6 times
4
7 times
5
More than7 times
-1
-2
Section 19: Height & Weight
D/K Ref.
124. About how much do you weigh without shoes?
___________ lbs. or ___________ kgs.
[ROUND FRACTIONS UP] [s19q124]
-1
(Do not ask Q126 or Q127)
-2
(Do not ask Q126 or Q127)
125. About how tall are you without shoes?
_________ ft __________inches or _________ meters
[ROUND FRACTIONS DOWN] [s19q125]
-1
-2
32
D/K Ref.
126. How much did you weigh a year ago? [If you were pregnant a year ago, how much did you weigh before your pregnancy?
___________ lbs. or ___________ kgs.
IF THE SAME AS LAST YEAR, GO TO SECTION 20. [s19q126]
-1
Skip to Section 20
-2
Skip to Section 20
127. Was the change between your current weight and your weight a year ago intentional? [s19q125]
1
Yes
0
No
-1
-2
Section 20: Weight Loss
Now, I'm going to ask you some questions about strategies for weight loss. Please tell me how likely you are to do each one. For example, “very likely”, “somewhat likely”, “somewhat unlikely”, “very unlikely”.
Very Likely
Somewhat Likely
Somewhat Unlikely
Very Unlikely D/K Ref.
128. If a doctor sug-gested that you need-ed to lose weight, how likely would you be to try to lose weight? [s20q128]
4
3
2
1
-1
-2
129. If you were to try to lose weight, how likely is it that you would join a weight loss group where you attend group sessions and follow a weight loss plan? [s20q129]
4
3
2
1
-1
-2
130. How likely is it that you would follow a weight loss plan from a book or tape? [s20q130]
4
3
2
1
-1
-2
131. How likely is it that you would change your diet on your own without following any particular program? [s20q131]
4
3
2
1
-1
-2
132. How likely is it that you would exercise on your own? [s20q132]
4
3
2
1
-1
-2
33
Very
Likely Somewhat
Likely Somewhat
Unlikely Very
Unlikely D/K Ref.
133. How likely is it that you would exercise in a group? (Note: 3 or more people) [s20q133]
4
3
2
1
-1
-2
134. How likely is it that you would take a weight loss pill? [s20q134]
4
3
2
1
-1
-2
135. Are you now trying to lose weight? [s20q135]
1
Yes
[SKIP TO Q137]
0
No
-1
Skip to Next Sec.
-2
Skip to Next Sec.
136. Are you now trying to maintain your current weight, that is, to keep from gaining weight?
1 Yes -> SKIP TO Q138
0 No -> SKIP TO NEXT SECTION [s20q136]
-1
Skip to Next Sec.
-2
Skip to Next Sec.
137. Are you eating fewer calories or less fat to lose weight? 1 Yes
0 No [s20q137]
-1
-2
138. Are you eating fewer calories or less fat to keep from gaining weight?
1 Yes
0 No [s20q138]
-1
-2
139. Are you using physical activity to lose weight/ keep from gaining weight?
1 Yes
0 No [s20q139]
-1
-2
140. In the past 12 months, has a health care provider given you advice about your weight?
1 Yes
2 No [s20q140]
-1
-2
34
Section 21: Oral Health
The next section on the survey is about oral health.
[READ RESPONSE OPTIONS IF NECESSARY] D/K Ref.
141. How long has it been since you last visited a dentist or a dental clinic for any reason? [s21q141]
1
Within the past year (1
to 12 months
ago)
2
1 to 2 years ago
3
2 to 5 years ago
4
5 or more years ago
-1
-2
142. How many of your permanent teeth have been removed because of tooth decay or gum disease? [s21q142]
1
1 to 5
2
6 or more, but not all
3
All
[SKIP TO NEXT
SECTION]
0
None
-1
-2
143. How long has it been since you had your teeth cleaned by a dentist or dental hygienist? [s21q143]
1
Within the past year (1
to 12 months
ago)
2
1 to 2 years ago
3
2 to 5 years ago
4
5 or more years ago
-1
-2
Section 22: Seatbelt Use
Ok, now I’m going to ask you about seatbelt use.
Always Nearly Always Sometimes Seldom Never D/K Ref.
144. How often do you use seatbelts when you drive or ride in a car?
[s22q144]
4
3
2
1
0
-1
-2
35
Section 23: Women’s Health
[IF RESPONDENT IS MALE, SKIP TO SECTION 24] Now I’m going to ask you about women’s health issues.
D/K Ref.
145. A clinical breast exam is when a doctor, nurse, or other health professional feels the breast for lumps. Have you ever had a clinical breast exam? [s23q145]
1
Yes
0
No
Skip to Q147
-1
Skip to Q147
-2
Skip to Q147
146. How long has it been since your last breast exam? 1 Within the past year (1 to 12 months ago)
2 1 to 2 years ago
3 2 to 5 years ago
4 5 or more years ago [s23q146]
-1
-2
147. A mammogram is an x-ray of each breast to look for breast cancer. Have you ever had a mammogram? [s23q147]
1
Yes
0
No
Skip to Q149
-1
Skip to Q149
-2
Skip to Q149
148. How long has it been since your last mammogram?
1 Within the past year (1 to 12 months ago)
2 1 to 2 years ago
3 2 to 5 years ago
4 5 or more years ago [s23q148]
-1
-2
149. A Pap test is a test for cancer of the cervix. Have you ever had a Pap test? [s23q149]
1
Yes
0
No
Skip to Section 24
-1
Skip to Section
24
-2
Skip to Section
24
150. How long has it been since your last Pap test?
1 Within the past year (1 to 12 months ago)
2 1 to 2 years ago
3 2 to 5 years ago
4 5 or more years ago [s23q150]
-1
-2
36
Section 24: Colorectal Screening
[If respondent is < 49 years of age, go to next section.] The next questions are about colorectal cancer screening.
D/K Ref.
151. Sigmoidoscopy and colonoscopy are exams in which a tube is inserted in the rectum to view the colon for signs of cancer or other health problems. Have you ever had either of these exams? [s24q151]
1
Yes
0
No
Skip to Section 25
-1
Skip to Section
25
-2
Skip to Section
25
152. How long has it been since your last sigmoidoscopy or colonoscopy?
1 Within the past year (less than 12 months ago)
2 Within past two years (1 year but less than 2 years ago)
3 Within past three years (2 years but less than 3 years ago)
4 Within past five years (3 years but less than 5 years ago)
5 Within past ten years (5 years but less than 10 years ago)
6 10 or more years ago [s24q152]
-1
-2
Section 25: Cancer Survivor
Now I’m going to ask you about cancer.
D/K Ref.
153. Have you EVER been told by a doctor, nurse, or other health professional that you had cancer?
Read only if necessary: By “other health professional” we mean a nurse practitioner, a physician’s assistant or some other licensed professional. [s25q153]
1
Yes
0
No
Skip to Section
26
-1
Skip to Section
26
-2
Skip to Section
26
154. How many different types of cancer have you had?
1 Only One
2 Two
3 Three or more [s25q154]
-1
-2
155. At what age were you told that you had cancer?
____________ years old [s25q155]
-1
-2
37
Section 26: Anxiety & Depression
The next section is about mental health. Okay, over the last week, how many days have you…
0 Days
1-2 Days
3-4 Days
5-7 Days
D/K Ref.
156. been bothered by things that usually don't bother you [s26q156]
0
1
2
3
-1
-2
157. had trouble keeping your mind on what you were doing [s26q157]
0
1
2
3
-1
-2
158. felt depressed [s26q158]
0
1
2
3
-1
-2
159. felt that everything you did was an effort [s26q159]
0
1
2
3
-1
-2
160. felt hopeful about the future [s26q160]
0
1
2
3
-1
-2
161. felt fearful [s26q161]
0
1
2
3
-1
-2
162. had restless sleep [s26q162]
0
1
2
3
-1
-2
163. felt happy [s26q163]
0
1
2
3
-1
-2
164. felt lonely [s26q164]
0
1
2
3
-1
-2
165. had difficulty "getting going" [s26q165]
0
1
2
3
-1
-2
Yes No D/K Ref.
166. Has a doctor or other healthcare provider EVER told you that you had an anxiety disorder? [DO NOT READ: including acute stress disorder, anxiety, generalized anxiety disorder, obsessive compulsive disorder, panic disorder, phobia, posttraumatic stress disorder, or social anxiety disorder] [s26q166]
1
0
-1
-2
38
Yes No D/K Ref.
167. Has a doctor or other healthcare provider EVER told you that you have a depressive disorder? [DO NOT READ: including depression, major depression, dysthymia, or minor depression, manic depression, bi-polar] [s26q167]
1
0
-1
-2
168. During the past year, have you received treatment, such as counseling, therapy, or medication, from a health professional, for feeling sad, blue or depressed? [s26q168]
1
0
-1
-2
Section 27: Emotional Support
Always Usually Sometimes Rarely Never D/K Ref.
169. How often do you get the social and emotional support you need? [READ ALL RESPONSE OPTIONS]
[If asked, say “please include support from any source.”] [s27q169]
4
3
2
1
0
-1
-2
Section 28: Life Satisfaction
Very
Satisfied Satisfied Dissatisfied Very
Dissatisfied D/K Ref.
170. In general, how satisfied are you with your life? [READ ALL RESPONSE OPTIONS] [s28q170]
4
3
2
1
-1
-2
Section 29: Spiritual Health
D/K Ref.
171. How often is meditation, prayer or spiritual exercise a part of your lifestyle? [READ ALL RESPONSE OPTIONS] [s29q171]
4
Always
3
Usually
2
Sometimes
1
Rarely
0
Never
-1
-2
39
D/K Ref.
172. How much do you agree with the following statement?... spiritual exercise plays a part in the quality of your life.
[READ RESPONSE OPTIONS] [s29q172]
4
Strongly Agree
3
Agree
2
Disagree
1
Strongly Disagree
-1
-2
173. Do you believe in faith as a factor in a healthy lifestyle? [s29q173]
1
Yes
0
No
-1
-2
Section 30: Preventive Counseling
***[ASK ONLY IF WITHIN 2 YEARS VISITIED A DOCTOR FOR A ROUTINE CHECK-UP - Q23 = WITHIN THE LAST YEAR OR 1 TO 2 YEARS AGO]*** Now, I’m going to ask you several questions about what your health care provider has talked to you about.
In the last 2 years, has a health care provider asked you about….
Yes No D/K Ref.
174. how often you drink alcohol? [s30q174]
1
0
-1
-2
175. the use of contraceptives or birth control? [s30q175]
1
0
-1
-2
176. your diet and eating habits? [s30q176]
1
0
-1
-2
177. whether you use marijuana, cocaine, or other drugs? [s30q177]
1
0
-1
-2
178. whether any guns at your home are stored safely? [s30q177]
1
0
-1
-2
179. the amount of physical activity or exercise you get? [s30q179]
1
0
-1
-2
180. physical or emotional abuse? [s30q180]
1
0
-1
-2
40
Yes No D/K Ref.
181. whether you wear a seat belt when driving or riding in a car? [s30q181]
1
0
-1
-2
182. sexually transmitted diseases? [s30q182]
1
0
-1
-2
183. whether you smoke cigarettes or used other forms of tobacco? [s30q183]
1
0
-1
-2
Section 31: Environment Assessment
We are getting close to the end. We have 4 more sections left. Okay, the next group of questions is about your neighborhood or environment.
D/K Ref.
184. Do you currently have a home vegetable garden? [s31q184]
1
Yes
0
No
-1
-2
185. How many minutes does it take you to drive from your house to a grocery store or market? [s31q185]
________ Minutes
-1
-2
186. How available are affordable fresh fruits, vegetables, and other healthful foods in your neighborhood? [s31q186]
4
Very available
3
Somewhat Available
2
Somewhat Unavailable
1
Very Unavailable
0
Never
-1
-2
187. Are there any parks or trails in your neighborhood where you can walk, run, or bike? [s31q187]
1
Yes
0
No
-1
-2
188. Do you have access to public exercise facilities such as walking or running tracks, basketball or tennis courts, swimming pools, sports fields, etc., in your neighborhood? [s31q188]
1
Yes
0
No
-1
-2
189. Are there sidewalks or shoulders of the road in your neighborhood sufficient to safely walk, run or bike? [s31q189]
1
Yes
0
No
-1
-2
41
Section 32: Personal Responsibility The next group of questions is about your attitudes about your health. Please indicate if you strongly agree, agree, disagree, or strongly disagree with each of the following statements.
[READ RESPONSE OPTIONS AGAIN IF NEEDED]
Strongly Agree Agree Disagree
Strongly Disagree D/K Ref.
190. My health largely depends on how well I take care of myself. [s32q190]
4
3
2
1
-1
-2
191. I think staying healthy is a matter of luck more than anything else. [s32q191]
4
3
2
1
-1
-2
192. I leave it to my doctor to make the right decisions about my health. [s32q192]
4
3
2
1
-1
-2
193. It is generally better to take care of your own health than to go to the doctor.
4
3
2
1
-1
-2
Section 33: Planning for the Future This group of questions pertains to your thoughts about the future.
Excellent Very Good Good Fair Poor D/K Ref.
194. In 5 years, how do you think you will rate your health? [s33q194]
5
4
3
2
1
-1
-2
195. In 5 years, how do you think you will rate your quality of life? [s33q195]
5
4
3
2
1
-1
-2
IF > 50 YEARS OF AGE -> GO TO NEXT QUESTION
IF < 50 YEARS OF AGE -> SKIP TO END The next group of questions is about aging.
42
None A Little A Lot Will Not Be
Able to Live Independently
D/K Ref.
196. In 5 years, how much assistance do you think that you will need from family and friends to continue to live independently in the community? [s33q196]
0
1
2
3
-1
-2
197. In 5 years, how much community-based assistance do you think that you will need to continue to live independently in the community? [READ: Community-based assistance includes but is not limited to services such as transportation, adult day care, meals, home health care, heating subsidies, and social activities.] [s33q197]
0
1
2
3
-1
-2
Section 34: Social Capital The last group of questions pertains to your thoughts about your community, and your involvement in your community. Please indicate how strongly you agree or disagree with each of the following statements:
Strongly Agree
Somewhat Agree
Neither Agree or Disagree
Somewhat Disagree
Strongly Disagree D/K Ref.
198. If there is a problem in my community, the people who live here work together to get it solved. [s34q198]
5
4
3
2
1
-1
-2
199. People in the community where I live are only out for themselves. [s34q199]
5
4
3
2
1
-1
-2
43
Strongly Agree
Somewhat Agree
Neither Agree or Disagree
Somewhat Disagree
Strongly Disagree D/K Ref.
200. I am afraid when I am out alone after dark in my community. [s34q200]
5
4
3
2
1
-1
-2
201. In my community, a small group of people has all the power. [s34q198]
5
4
3
2
1
-1
-2
202. I feel like an outsider in my community. [s34q202]
5
4
3
2
1
-1
-2
203. There is nothing I can do to solve problems in my community when they happen. [s34q203]
5
4
3
2
1
-1
-2
204. In my community most people can be trusted. [s34q204]
5
4
3
2
1
-1
-2
205. In my community, most people would try to take advantage of you if they got a chance. [s34q205]
5
4
3
2
1
-1
-2
206. In my community, you can’t be too careful in dealing with people. [s34q206]
5
4
3
2
1
-1
-2
These questions will ask about your participation in community groups:
Yes No D/K Ref.
207. In the last twelve months, have you attended a meeting of a school board, city council, or other official government body? [s34q207]
1
0
-1
-2
44
Please answer the following with how likely your neighbors would be to intervene in the following situations:
Very Likely to Intervene
Somewhat Likely to Intervene
Somewhat Unlikely to Intervene
Very Unlikely to Intervene
D/K
Ref.
208. If your neighbors saw children skipping school and just hanging out during school hours, how likely would your neighbors be to intervene in some way? [s34q208]
4
3
2
1
-1
-2
209. If your neighbors saw children marking buildings with graffiti, how likely would your neighbors be to intervene in some way? [s34q209]
4
3
2
1
-1
-2
210. If your neighbors observed a fight breaking out in front of your house, how likely would your neighbors be to intervene in some way? [s34q210]
4
3
2
1
-1
-2
211. Using a scale of one
to five, with one being not at all proud, and five being very proud, how much pride do you have in your community [s34q211]
1
Not Proud at All
2
3
4
5
Very Proud
D/K
-1
Ref.
-2
Now I am going to read a list of different community organizations. Please tell me if you belong to any of the following:
Yes No D/K Ref.
212. Business civic groups like Kiwanis or Rotary. [s34q212]
1
0
-1
-2
213. Religious organizations, such as a church or synagogue. [s34q213]
1
0
-1
-2
214. Charity or volunteer organizations. [s34q214]
1
0
-1
-2
45
Yes No D/K Ref.
215. Ethnic or racial organizations. [s34q215]
1
0
-1
-2
216. Neighborhood associations. [s34q216]
1
0
-1
-2
217. PTA or other school related groups. [s34q217]
1
0
-1
-2
218. Political clubs or organizations. [s34q218]
1
0
-1
-2
219. Social clubs, such as playing cards, music, hobbies, book club, etc. [s34q219]
1
0
-1
-2
220. Other, please specify:
________________________________ [s34q220]
1
0
-1
-2
Thank you for your time. The purpose of this survey is to better understand the health conditions and practices of the residents in the San Luis Valley. Your responses are very valuable to this study and to improving the health and well-being of SLV residents.
46
Interviewer Perceptions
[To be filled in at completion of interview] Poor Fair Good Can’t Judge
221. How was the respondent’s comprehension of the questionnaire? [ipq222]
1
2
3
-3
222. How satisfactory was the information provided by the respondent? [ipq223]
1
2
3
-3
[If your answer is poor, fair, or can’t judge, complete comments section]
Interviewer Comments: ___________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________
