Valuing Reduced Asthma Episodes For Adults And Children -- Focus Groups

Knowledge Networks, Inc. 2233801

UCF

Asthma Survey: Child Version

[RADIO BUTTONS]

Single Punch Answer

Q1. Has a doctor or health professional ever said that your child has asthma?

Yes A

No B

[IF Q1 = B  TERMINATE SURVEY. ESLE IF Q1 = A, CONTINUE.]

[RADIO BUTTONS]

Single Punch Answer

Q2. About how old was your child when a doctor (or health professional) first said that he or she had asthma?

3 years old or younger A

4 years old B

5 years old C

6 years old D

7 years old E

8 years old F

9 years old G

10 years old H

11 years old I

12 years old J

13 years old K

14 years old L

15 years old M

16 years old N

17 years old or older O

[DISPLAY]

Some people with asthma are not bothered by asthma symptoms every day. They have some days when no symptoms are present, or days when asthma symptoms are present but don’t really cause discomfort or bother.

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Single Punch Answer

Q3. During the past 12 months, about how often have asthma symptoms caused your child discomfort or bother?

Every day A

Most days B

Some days C

Never D

[IF Q3 = “NEVER”  TERMINATE SURVEY.

ELSE  CONTINUE.]

[IF Q3 = “EVERY DAY”  SET “NDAYSYR” = 365.]

[RADIO BUTTONS]

Single Punch Answer

Q3A. On the days that your child’s asthma symptoms cause discomfort or bother, about how much of the day do the symptoms typically bother your child?

All day A

Most of the day B

Some of the day C

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Single Punch Answer

Q4. Compared to one year ago, how well controlled is your child’s asthmas?

Better than one year ago A

About the same as one year ago B

Worse than one year ago C

[RADIO BUTTONS]

Single Punch Answer

Q5. Apart from asthma, has a doctor or health professional ever said that your child has any serious, long term condition that affects his or her lungs or breathing – such as chronic obstructive pulmonary disease (COPD), chronic bronchitis, or emphysema?

Yes A

No B

[IF Q5 = A  ASK Q5A. ELSE  SKIP TO Q6.]

[IF Q5 = A]

[RADIO BUTTONS]

Single Punch Answer

Q5A. Does that condition affect the frequency or severity of your child’s asthma symptoms?

Yes A

No B

[RADIO BUTTONS]

Single Punch Answer

Q6. In general, would your child say that your child’s health is excellent, very good, good, fair or poors?

Excellent A

Very Good B

Good C

Fair D

Poor E

This screen shows a scale used to rate how healthy you think your child is. The scale goes from 0 to 100. On the scale, 100 means “perfect health” and 0 means “death”. In between 0 and 100, higher numbers indicate better health.

[Display like a thermometer, with 101 “steps” ranging from 0 to 100. The “tens” are labeled, e.g., 0, 10, 20, …, 100. At zero, a text box or arrow indicates “Death”. At 100, a text box or arrow indicates “Perfect health.”]

Q7. Please use the scale to rate how healthy you think your child is. To use the scale, enter a number between 0 and 100 in the box below/next to the scale. After you enter a number in the box, your answer will be shown on the scale. Then, you will have a chance to change your answer if your child want.

[Bring up the display. Next to the number box the text reads: Please enter a number between 0 and 100. Respondent enters a number in the box. The thermometer “fills up” to that point on the scale. E.g. if 75 is entered, the thermometer is filled in red up to 75. An indication like an arrow or text box confirms “Your child’s health 75”.

Q7A. You indicated that your child’s overall state of health is about [INSERT ANSWER TO Q7] on a scale of 0 to 100.

Would you like to change your answer or are your child satisfied with your answer?

I would like to change my answer, please go back. A

I am satisfied with my answer, please continue. B

[IF Q7a = A  LOOP BACK THROUGH Q7 AND Q7A TO GET CORRECT RATING.

ELSE IF Q7A = B  CONTINUE WITH NEXT DISPLAY.]

Q8. Now, try to imagine what your child’s health would be like if asthma did not affect him or her. Imagine that your child was never bothered by asthma symptoms, and did not need to take any asthma medication. On the same scale of 0 to 100, how would you rate your child’s health if he or she did not have asthma?

[Bring up the thermometer with the previous answer (Q7) still shown. Respondent enters another number in the box.] The thermometer “fills up” to that point on the scale in a different color. E.g. if 95 is entered, the thermometer is filled in red up to the previous answer (Q7), and in green up to 95. An indication like an arrow or text box confirms “Your child’s health without asthma 95”.

Q8A. You indicated that your child’s overall state of health would be about [INSERT ANSWER TO Q8] on a scale of 0 to 100, if your child did not have asthma.

Would you like to change your answer or are your child satisfied with your answer?

I would like to change my answer, please go back. A

I am satisfied with my answer, please continue. B

[IF Q8A = A  LOOP BACK THROUGH Q8 AND Q8A TO GET CORRECT RATING.

ELSE IF Q8A = B  CONTINUE WITH Q9.]

[RADIO BUTTONS]

Single Punch Answer

Q9. During the past 12 months, about how often has your child visited a doctor or health care professional mainly for the purpose of getting treatment or advice for asthma?

0 times A

1 time B

2 times C

3 times D

4 times E

5 times F

6 times G

7 times H

8 times I

9 times J

10 times K

11 times L

12 times M

More than 12 times N

[DISPLAY]

We would like to find out about the costs of medical care and medications to control your child’s asthma.

People have different ways of paying for medical care and drugs.

• Some people have health insurance, belong to HMOs, or use government plans like Medicare or Medicaid to cover some or all of their health care costs.

• Some people pay all or part of their health care costs out of their own pockets.

• And some people have flexible spending plans through their jobs. In a flexible spending plan, money gets deducted from the paycheck and saved up to reimburse health care expenses that are not covered by insurance.

When we ask about “insurance or other health plan,” we mean things like health insurance, HMOs, PPO plans, Medicare and Medicaid, not flexible spending plans.

[RADIO BUTTONS]

Single Punch Answer

Q10. If your child visits a doctor or health care professional for asthma, does health insurance or other health plan cover at least part of the cost? (Please do not count flexible spending plans.)

Yes A

No B

[IF Q10 = A  ASK Q10A. ELSE  SKIP TO Q10B.]

[IF Q10 = A]

[RADIO BUTTONS]

Single Punch Answer

Q10A. Does insurance or other health plan cover all, or only part, of the cost?

Insurance/health plan covers all of cost A

Insurance/health plan covers part of cost B

[IF Q10A = B  ASK Q10B. IF Q10A=A  SKIP TO Q11.]

[IF Q10A = A OR IF Q10=B]

[RADIO BUTTONS]

Single Punch Answer

Q10B. About how much would you expect to pay, the next time your child visits a doctor for asthma? Please count only your out-of-pocket expense (even if you were reimbursed by a flexible spending plan). Do not include any amount that would be paid or reimbursed by insurance or other health plan.

$5 or less A

$6 to $10 B

$11 to $15 C

$16 to $20 D

$21 to $25 E

$26 to $30 F

$31 to $35 G

$36 to $40 H

$41 to $45 I

$46 to $50 J

$51 to $60 K

$61 to $70 L

$71 to $80 M

$81 to $90 N

$91 to $100 O

More than $100 P

[RADIO BUTTONS]

Single Punch Answer

Q11. If your child visits a doctor for his or her asthma, about how much time does it usually take? Please include travel time there and back, time spent waiting to see the doctor, and the time spent with the doctor.

1/2 hour or less A

Between ½ and 1 hour B

Between 1 and 1½ hours C

Between 1½ and 2 hours D

Between 2 and 2½ hours E

Between 2½ and 3 hours F

Between 3 and 3½ hours G

Between 3½ and 4 hours H

4 hours or more I

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Single Punch Answer

Q12. When your child visits a doctor for asthma, do you usually take time off from working at a job or business to take your child to the doctor?

Yes A

No B

[RADIO BUTTONS]

Single Punch Answer

Q13. During the past 12 months, has your child taken any prescription medications for asthma?

Yes A

No B

[IF Q13 = B  SKIP TO DISPLAY BEFORE Q20 .

IF Q13 = A  BEGIN CURRENT DRUG MODULE AT Q14.]

We would like to find out about the medicines your child takes to control asthma, and how much these medicines cost.

[RADIO BUTTONS]

Single Punch Answer

Q14. Are your child’s medications currently covered by any kind of prescription drug plan that pays all or part of the costs of asthma medications? (Again, please do not count flexible spending plans.)

Yes A

No B

[RADIO BUTTONS]

Single Punch Answer

Q15. During the past 12 months, has your child taken any inhaled, “rescue” or “quick-relief” bronchodilator medicines for asthma? These medications are meant to be taken as needed to relieve asthma symptoms. Examples include Albuterol, Alupent, Atrovent, Bitolterol, Brethaire, Maxair, Metaproteronol, Tornalate, Terbutaline, Proventil, Ventolin.

Yes A

No B

[IF Q15 = A  ASK Q15A - Q15D. ELSE  SKIP TO Q16.]

[IF Q15 = A]

[RADIO BUTTONS]

Single Punch Answer

Q15A. On average during the past 12 months, about how often has this prescription been filled for your child?

Every month A

Every 6 weeks B

Every 2 months C

Every 3 months D

Every 4 to 6 months E

Less often than every 6 months F

[IF Q15 = A]

[RADIO BUTTONS]

Single Punch Answer

Q15B. When this prescription has been filled during the past year, about how much did it cost each time? Please count only your out-of-pocket expense. Do not include any amount that would be paid or reimbursed by a drug plan, insurance, or other health care coverage.

$5 or less A

$6 to $10 B

$11 to $15 C

$16 to $20 D

$21 to $25 E

$26 to $30 F

$31 to $35 G

$36 to $40 H

$41 to $45 I

$46 to $50 J

$51 to $60 K

$61 to $70 L

$71 to $80 M

$81 to $90 N

$91 to $100 O

More than $100 P

[IF Q15 = A]

[RADIO BUTTONS]

Single Punch Answer

Q15C. During the months of the year that your child has asthma symptoms, about how often does he or she use the rescue inhaler?

Every day A

More than two days per week but not every day B

About two days per week C

About one day per week D

Less than one day per week E

[IF Q15 = A]

[RADIO BUTTONS]

Single Punch Answer

Q15D. During the months of the year that your child has asthma symptoms, about how long does one canister of the rescue inhaler last?

Less than 2 weeks A

2 weeks to less than one month B

1-2 months C

2-3 months D

More than 3 months E

[RADIO BUTTONS]

Single Punch Answer

Q16. During the past 12 months, has your child taken any inhaled anti-inflammatory medicines for asthma? These are long-term control or “preventer” medications that are meant to be taken every day (e.g., twice daily). Examples include Aerobid, Advair, Azmacort, Beclomethasone dipropionate, Beclovent, Budesonide, Cromolyn, Flovent, Flunisolide, Fluticasone, Intal, Nedocromil, Pulmicort Turbuhaler, Tilade, Triamcinolone acetonide, Vanceril.

Yes A

No B

[IF Q16 = A  ASK Q16A and Q16B. ELSE  SKIP TO Q17.]

[IF Q16 = A]

[RADIO BUTTONS]

Single Punch Answer

Q16A. On average during the past 12 months, about how often has this prescription been filled for your child?

Every month A

Every 6 weeks B

Every 2 months C

Every 3 months D

Every 4 to 6 months E

Less often than every 6 months F

[IF Q16 = A]

[RADIO BUTTONS]

Single Punch Answer

Q16B. When this prescription has been filled during the past year, about how much did it cost each time? Please count only your out-of-pocket expense. Do not include any amount that would be paid or reimbursed by a drug plan, insurance, or other health care coverage.

$5 or less A

$6 to $10 B

$11 to $15 C

$16 to $20 D

$21 to $25 E

$26 to $30 F

$31 to $35 G

$36 to $40 H

$41 to $45 I

$46 to $50 J

$51 to $60 K

$61 to $70 L

$71 to $80 M

$81 to $90 N

$91 to $100 O

More than $100 P

[CONTINUE WITH Q17.]

[RADIO BUTTONS]

Single Punch Answer

Q17. During the past 12 months, has your child taken any inhaled, long-acting bronchodilator medicines for asthma? These are also long-term control or “preventer” medications and are meant to be taken every day (e.g., twice daily). Examples include Advair, Salmeterol, Serevent, Serevent Diskus.)

Yes A

No B

[IF Q17 = A  ASK Q17A and Q17B. ELSE  SKIP TO Q18.]

[IF Q17 = A]

[RADIO BUTTONS]

Single Punch Answer

Q17A. On average during the past 12 months, about how often has this prescription been filled for your child?

Every month A

Every 6 weeks B

Every 2 months C

Every 3 months D

Every 4 to 6 months E

Less often than every 6 months F

[IF Q17 = A]

[RADIO BUTTONS]

Single Punch Answer

Q17B. When this prescription has been filled during the past year, about how much did it cost each time? Please count only your out-of-pocket expense. Do not include any amount that would be paid or reimbursed by a drug plan, insurance, or other health care coverage.

$5 or less A

$6 to $10 B

$11 to $15 C

$16 to $20 D

$21 to $25 E

$26 to $30 F

$31 to $35 G

$36 to $40 H

$41 to $45 I

$46 to $50 J

$51 to $60 K

$61 to $70 L

$71 to $80 M

$81 to $90 N

$91 to $100 O

More than $100 P

[CONTINUE WITH Q18.]

[RADIO BUTTONS]

Single Punch Answer

Q18. During the past 12 months, has your child taken any pills or tablets for asthma? (Examples: Accolate, Aerolate, Deltasone, Pediapred, Prednisone, Medrol, Singulair, Theophylline, Zafirlukast, Zileuton, Zyflo Filmtab).

Yes A

No B

[IF Q18 = A  ASK Q18A and Q18B. ELSE  SKIP TO Q20.]

[IF Q18 = A]

[RADIO BUTTONS]

Single Punch Answer

Q18A. On average during the past 12 months, about how often has this prescription been filled for your child?

Every month A

Every 6 weeks B

Every 2 months C

Every 3 months D

Every 4 to 6 months E

Less often than every 6 months F

[IF Q18 = A]

[RADIO BUTTONS]

Single Punch Answer

Q18B. When this prescription has been filled during the past year, about how much did it cost each time? Please count only your out-of-pocket expense. Do not include any amount that would be paid or reimbursed by a drug plan, insurance, or other health care coverage.

$5 or less A

$6 to $10 B

$11 to $15 C

$16 to $20 D

$21 to $25 E

$26 to $30 F

$31 to $35 G

$36 to $40 H

$41 to $45 I

$46 to $50 J

$51 to $60 K

$61 to $70 L

$71 to $80 M

$81 to $90 N

$91 to $100 O

More than $100 P

[RADIO BUTTONS]

Single Punch Answer

Q19. During the past 12 months, about how often have side effects from asthma medications caused your child discomfort or bother?

Every day A

Most days B

Some days C

Never D

[IF Q19 NOT = D  ASK Q19A. ELSE IF Q19 = D,  SKIP TO Q20.]

[RADIO BUTTONS]

Single Punch Answer

Q19A. On the days that side effects from asthma medications cause your child discomfort or bother, about how severe were the side effects?

Severe A

Moderate B

Mild C

[CONTINUE.]

[IF Q3 = A “every day”  SKIP TO Q22 .]

ELSE  CONTINUE WITH Q20.]

[IF Q3 NOT = A]

[RADIO BUTTONS]

Single Punch Answer

Q20. During the past 12 months, have asthma symptoms caused your child discomfort or bother at some time during every month or only during some months?

Every month A

Some months B

[IF Q20 = A  SET “NMTHSYR” = 12, AND SKIP TO Q22.

ELSE  ASK Q20A.]

[IF Q20 NOT = A]

Q20A. The next screen shows a calendar for the past 12 months. Please select all of the months in the past year when asthma symptoms caused your child discomfort or bother on at least one day of the month.

[DISPLAY] 12 boxes, consecutively labeled with months of the year. Each box can be selected as a multi-punch answer.

[SAVE NUMBER OF MONTHS SELECTED IN Q20A AS “NMTHSYR”.

CONTINUE WITH Q21.]

[RADIO BUTTONS]

Single Punch Answer

Q21. During the months of the past year when your child’s asthma symptoms have caused discomfort or bother, have the symptoms bothered your child every day of the months, or only some days?

Every day A

Some days B

[IF Q21 = A,  SET “NDAYSYR” = 30*NMTHSYR AND SKIP TO Q22.

(NOTE: NMTHSYR BASED ON Q20 OR Q20A.)

ELSE  ASK Q21A.]

[IF Q21 NOT = A]

[RADIO BUTTONS]

Single Punch Answer

Q21A. Please recall the months during the past 12 when asthma symptoms have caused discomfort or bother. On the average, about how many days per month did symptoms cause your child discomfort or bother? (Assume 30 days in a month.)

Answer options are 1,2,…,30.

[SET “NDAYSYR” = (NUMBER OF DAYS IN Q216) * NMTHSYR.

NOTE: NMTHSYR BASED ON Q20 OR Q20A.]

[RADIO BUTTONS]

Single Punch Answer

Q22. Based on your answers to previous questions, it appears that asthma symptoms caused your child discomfort or bother on about [INSERT NDAYSYR] days during the past 12 months. Is that about the right number of days?

Yes A

No B

[IF Q22 = A  SKIP TO DISPLAY.

ELSE IF Q22 = B  ASK Q22B.]

Number Box Answer

[Number Box]

Range 0 – 365

Q22B. About how many days during the past 12 months did asthma symptoms cause your child discomfort or bother?

Please enter a number from 0 through 365 in the box below:

[SET “NDAYSYR” = ANSWER TO Q22B, AND CONTINUE WITH Q22C.]

Q22C. You indicated that asthma symptoms caused your child discomfort or bother on [INSERT NDAYSYR (=ANSWER TO Q22B)] days during the past year.

Would you like to change your answer or are your child satisfied with your answer?

I would like to change my answer, please go back. A

I am satisfied with my answer, please continue. B

[IF Q22C = A  LOOP BACK THROUGH Q22B AND Q22C TO GET CORRECT NUMBER OF DAYS.

ELSE IF Q22C = B  CONTINUE WITH DISPLAY.]

[DISPLAY]

This display shows the number of days during the past year when asthma symptoms caused your child discomfort or bother. In the rest of the survey, we’ll refer to these [INSERT NDAYSYR] as “asthma symptom days.”

[DISPLAY] A bar chart with one vertical bar in one color, e.g., green.

Height of bar = NDAYSYR.

Next we would like to find out how much asthma symptoms interfered with your child’s activities on these [INSERT NDAYSYR] asthma symptom days.

[RADIO BUTTONS]

Single Punch Answer

Q23. Thinking about your child’s [INSERT NDAYSYR] asthma symptom days during the past year, were there any days when asthma symptoms caused your child to make an urgent or unscheduled visit to an emergency room, hospital, health clinic or doctor’s office, or to stay overnight in a hospital?

Yes A

No B

[IF Q23 = A  ASK Q23A.

IF Q23 = B  SET “NSEVERE” = 0 AND SKIP TO Q24.]

[IF Q23 = A]

[Number Box]

Range 1 – ndaysyr

Q23A. About how many days during the past 12 months did asthma symptoms cause your child to make an urgent or unscheduled visit to an emergency room, hospital, health clinic or doctor’s office, or to stay overnight in a hospital?

Please enter a number from 1 through [INSERT NDAYSYR] in the box below:

[SAVE NUMBER OF DAYS IN Q23A “NSEVERE”.]

[IF Q23 = A]

[RADIO BUTTONS]

Single Punch Answer

Q23B. You indicated that your child’s asthma symptoms caused your child to visit an emergency room, hospital, health clinic or doctor’s office, or to stay overnight in a hospital, on [INSERT NSEVERE (=ANSWER TO Q23A)] days during the past year.

Would you like to change your answer or are your child satisfied with your answer?

I would like to change my answer, please go back. A

I am satisfied with my answer, please continue. B

[IF Q23B=A  LOOP BACK THROUGH Q23A & Q23B TO GET CORRECT NUMBER OF DAYS.

ELSE CONTINUE WITH DISPLAY BEFORE Q24.]

[IF Q23 = A]

[Number Box]

Range 1 – ndaysyr

Q23C. About how many nights, if any, did your child stay overnight in a hospital because of his or her asthma?

Please enter a number from 0 through [INSERT NSEVERE] in the box below:

[IF Q23 = A]

[Number Box]

Range 1 – ndaysyr

Q23D. About how many days, if any, did your child visit an emergency room for urgent treatment of asthma symptoms?

Please enter a number from 0 through [INSERT NSEVERE] in the box below:

[IF Q23 = A  INSERT BEFORE Q24:]

Please do not count those [INSERT NSEVERE] days when you answer the next question. Please think only about your child’s remaining [INSERT NDAYSYR - NSEVERE] asthma symptom days.

[RADIO BUTTONS]

Single Punch Answer

Q24. Thinking about your child’s [INSERT NDAYSYR – NSEVERE] asthma symptom days during the past year, were there any days when your child’s asthma symptoms…

interfered with most of his or her activities, or awakened your child at night or significantly disturbed his/her sleep, or caused your child to leave school, or to stay home, or caused a someone to telephone a doctor or nurse?

Yes A

No B

[IF Q24 = A  ASK Q24A.

IF Q24 = B  SET “NBAD” = 0 AND SKIP TO Q25.]

[IF Q24 = A  INSERT BEFORE Q24A:]

Again, please do not count the [INSERT NSEVERE] days when your child was in the hospital for asthma, or when asthma symptoms caused your child to need urgent medical attention when answering the next question.

[IF Q24 = A]

[Number Box]

Range 1 – (ndaysyr minus nsevere)

Q24A. On about how many of the [INSERT NDAYSYR - NSEVERE] days did asthma symptoms interfere with most of your child’s activities, awaken him/her at night or significantly disturb his/her sleep, or cause your child to leave school, or to stay home, or cause someone to telephone a doctor or nurse?

Please enter a number from 1 through [INSERT NDAYSYR - NSEVERE] in the box below:

[SAVE NUMBER OF DAYS IN Q24A “NBAD”.]

[IF Q24 = A]

[RADIO BUTTONS]

Single Punch Answer

Q24B. You indicated that there were [INSERT NBAD (=ANSWER TO Q24A)] days during the past year when asthma symptoms interfered with most of your child’s activities or sleep, or caused your child to leave school, or to stay home, or caused someone to telephone a doctor or nurse.

Would you like to change your answer or are you satisfied with your answer?

I would like to change my answer, please go back. A

I am satisfied with my answer, please continue. B

[IF Q24B=A  LOOP BACK THROUGH Q24A & Q24B TO GET CORRECT NUMBER OF DAYS.

ELSE CONTINUE WITH Q24C.]

[RADIO BUTTONS]

Single Punch Answer

Q24C. Did your asthma symptoms cause your child to miss school on any of those [INSERT NBAD] days?

Yes A

No B

[IF Q24C = A  ASK Q24D.

IF Q24C = B  SKIP TO Q24F.]

[IF Q24C = A]

[Number Box]

Range 1 – nbad

Q24D. On about how many of those [INSERT NBAD] days did your asthma symptoms cause your child to miss school?

Please enter a number from 1 through [INSERT NBAD] in the box below:

[SAVE NUMBER OF DAYS IN Q24D “NWLD”.]

[IF Q24C = A]

[RADIO BUTTONS]

Single Punch Answer

Q24E. You indicated that asthma symptoms caused your child to miss school on [INSERT NWLD (=ANSWER TO Q24D)] days.

Would you like to change your answer or are you satisfied with your answer?

I would like to change my answer, please go back. A

I am satisfied with my answer, please continue. B

[IF Q24E=A  LOOP BACK THROUGH Q24D & Q24E TO GET CORRECT NUMBER OF DAYS.

ELSE CONTINUE WITH Q24F.]

[RADIO BUTTONS]

Single Punch Answer

Q24F. Thinking about those [INSERT NBAD] days during the past year, were there any times when your asthma symptoms awakened your child at night or significantly disturbed his or her sleep?

Yes A

No B

[IF Q24F = A  ASK Q24G.

IF Q24F = B  SKIP TO Q25.]

[IF Q24F = A]

[Number Box]

Range 1 – ndaysyr

Q24G. About how many nights did asthma symptoms awaken your child at night or significantly disturbed his or her sleep?

Please enter a number from 1 through [INSERT NBAD] in the box below:

[SAVE NUMBER OF DAYS IN Q24G “NAWAKE”.]

[IF Q24F = A]

[RADIO BUTTONS]

Single Punch Answer

Q24H. You indicated that asthma symptoms awakened your child at night or significantly disturbed his or her sleep [INSERT NAWAKE (=ANSWER TO Q24G)] days during the past year.

Would you like to change your answer or are you satisfied with your answer?

I would like to change my answer, please go back. A

I am satisfied with my answer, please continue. B

[IF Q24H=A  LOOP BACK THROUGH Q24G & Q24H TO GET CORRECT NUMBER OF DAYS.

ELSE CONTINUE.]

[IF Q23 = A  INSERT BEFORE Q25:]

Please do not count the [INSERT NSEVERE] days when your child was in the hospital for asthma, or when your asthma symptoms caused your child to need urgent medical attention, when you answer the next question.

[IF Q24 = A  INSERT BEFORE Q25:]

Please do not count the [INSERT NBAD] days when asthma symptoms interfered with most of your child’s activities, or awakened your child at night or significantly disturbed his/her sleep, or caused your child to leave school, or to stay home, or caused someone to telephone a doctor or nurse, when you answer the next question.

[RADIO BUTTONS]

Single Punch Answer

Q25. Thinking about the [INSERT NDAYSYR - NSEVERE - NBAD] asthma symptom days, were there any days when asthma symptoms interfered somewhat with your child’s activities or sleep?

Yes A

No B

[IF Q25 = A  ASK Q25A.

IF Q25 = B  SET “NMOD” = 0 AND SKIP TO DISPLAY BEFORE Q26.]

[IF Q18 = A  INSERT BEFORE Q25A:]

Again, please do not count the [INSERT NSEVERE] days when your child was in the hospital for asthma, or when your child’s symptoms caused your child to need urgent medical attention, when you answer the next question.

[IF Q24 = A  INSERT BEFORE Q25A:]

Again, please do not count the [INSERT NBAD] days when asthma symptoms interfered with most of your child’s activities, or awakened your child at night or significantly disturbed his/her sleep, or caused your child to leave, or to stay home, or caused someone to telephone a doctor or nurse, when you answer the next question.

[IF Q25 = A]

Number Box Answer

[Number Box]

Range 1 – (ndaysyr minus nsevere minus nbad)

Q25A. Thinking about the [INSERT NDAYSYR - NSEVERE - NBAD] asthma symptom days, about how many days did asthma symptoms interfere somewhat with your child’s activities or sleep?

Please enter a number from 1 through [INSERT NDAYSYR – NSEVERE - NBAD] in the box below:

[SAVE NUMBER OF DAYS IN Q25A “NMOD”.]

[IF Q25 = A]

[RADIO BUTTONS]

Single Punch Answer

Q25B. You indicated that there were [INSERT NMOD (=ANSWER TO Q25A)] days during the past year when asthma symptoms interfered somewhat with your child’s activities or sleep.

Would you like to change your answer or are you satisfied with your answer?

I would like to change my answer, please go back. A

I am satisfied with my answer, please continue. B

[IF Q25B=A  LOOP BACK THROUGH Q25A & Q25B TO GET CORRECT NUMBER OF DAYS.

ELSE CONTINUE WITH DISPLAY BEFORE Q26.]

[DISPLAY]

Based on your answers, this display shows your child’s asthma symptom days during the past year. The green bar shows the [INSERT NDAYSYR – NSEVERE – NBAD - NMOD] days when your child’s asthma symptoms caused discomfort or bother, but didn’t really interfere with your child’s activities.

If you said that asthma symptoms interfered with your child’s activities on any days during the past year, these days are shown in a different color.

[IF NMOD > 0:] The [INSERT NMOD] days when you said your child’s asthma symptoms interfered somewhat with his or her activities or sleep are shown in yellow.

[IF NBAD > 0:] The [INSERT NBAD] days when you said your child’s asthma symptoms interfered with most of your child’s activities, or awakened your child at night/significantly disturbed his/her sleep, or caused your child to leave school, or to stay home, or caused someone to telephone a doctor or nurse, are shown in orange.

[IF NSEVERE > 0:] The [INSERT NSEVERE] days when you said that your child stayed overnight in a hospital, or visited an emergency room, hospital, health clinic or doctor’s office for urgent treatment of asthma symptoms, are shown in red.

The overall height of the bar shows your child’s total number of [INSERT NDAYSYR] asthma symptom days during the past year.

[DISPLAY] A bar chart with one vertical bar.

• Total height of bar = NDAYSYR.

• Bottom segment = GREEN: Height = Residual of [NDAYSYR – NSEVERE – NBAD – NMOD].

• Next segment = YELLOW: Height = NMOD, IF NMOD > 0.

• Next segment = ORANGE: Height = NBAD, IF NBAD > 0.

• Next segment = RED: Height = NSEVERE, IF NSEVERE > 0.

[NOTE: The next section gets descriptions of asthma symptom days.

For Respondents who reported interference with activities in q23, Q24, or Q25, pick a day in the most severe category, and characterize the day.

If worst day = medical attention, go to q26A-q29A.

If worst day = interfere most activities, go to q26B-q29B.

if worst day = interfere somewhat, go to q26C-q29C.

Then, for ALL respondents, characterize a day when asthma symptoms cause discomfort or bother, but do not interfere with activities. This is the loop Q30-Q33.]

[DISPLAY]

Next we would to find out the kinds of symptoms your child has when asthma symptoms cause discomfort or bother.

[IF Q23=A  ASK Q26A through Q29A.

ELSE IF Q23=B AND Q24=A  ASK Q26B through Q29B.

ELSE IF Q23=B AND Q24=B AND Q25=A  ASK Q26C through Q29C.

ELSE IF Q23=B AND Q24=B AND Q25=B  SKIP TO Q30.]

[IF Q23=A]

Q26A. Please recall a day when asthma symptoms caused your child to make an urgent or unscheduled visit to an emergency room, hospital, health clinic or doctor’s office, or to stay overnight in a hospital. Which of the following symptoms did your child experience? (Please select all that apply.)

Cough A

Phlegm/Sputum B

Chest tightness C

Wheeze D

Shortness of breath E

Other symptoms F

[IF Q23=A]

[RADIO BUTTONS]

Single Punch Answer

Q27A. Which of those symptoms was the most bothersome? (Please choose one answer.)

Cough A

Phlegm/Sputum B

Chest tightness C

Wheeze D

Shortness of breath E

Some other symptom F

No single symptom was most bothersome G

[IF Q23=A]

[RADIO BUTTONS]

Single Punch Answer

Q28A. About how long did these episodes last on average?

Less than an hour A

One to a few hours B

All day or night C

Continuing for the next 1 or 2 days D

Continuing for the next 3 days or longer E

[IF Q23=A]

[RADIO BUTTONS]

Single Punch Answer

Q29A. During episodes like this, did your child use a rescue inhaler more than he or she would on days when asthma symptoms were less bothersome?

Yes A

No B

[SKIP TO Q30.]

[IF Q23=B AND Q24=A]

Q26B. Please recall a day when asthma symptoms interfered with most of your child’s activities, or awakened your child at night/significantly disturbed his or her sleep, or caused your child to leave school, or to stay home, or caused someone to telephone a doctor or nurse. Which of the following symptoms did your child experience? (Please select all that apply.)

Cough A

Phlegm/Sputum B

Chest tightness C

Wheeze D

Shortness of breath E

Other symptoms F

[IF Q23=B AND Q24=A]

[RADIO BUTTONS]

Single Punch Answer

Q27B. Which of those symptoms was the most bothersome? (Please choose one answer.)

Cough A

Phlegm/Sputum B

Chest tightness C

Wheeze D

Shortness of breath E

Some other symptom F

No single symptom was most bothersome G

[IF Q23=B AND Q24=A]

[RADIO BUTTONS]

Single Punch Answer

Q28B. About how long did these episodes last on average?

Less than an hour A

One to a few hours B

All day or night C

Continuing for the next 1 or 2 days D

Continuing for the next 3 days or longer E

[IF Q23=B AND Q24=A]

[RADIO BUTTONS]

Single Punch Answer

Q29B. During episodes like this, did your child use a rescue inhaler more than he or she would on days when asthma symptoms were less bothersome?

Yes A

No B

[SKIP TO Q30.]

[IF Q23=B AND Q24=B AND Q25=A]

Q26C. Please recall a day when asthma symptoms interfered somewhat with your child’s activities or sleep. Which of the following symptoms did your child experience? (Please select all that apply.)

Cough A

Phlegm/Sputum B

Chest tightness C

Wheeze D

Shortness of breath E

Other symptoms F

[IF Q23=B AND Q24=B AND Q25=A]

[RADIO BUTTONS]

Single Punch Answer

Q27C. Which of those symptoms was the most bothersome? (Please choose one answer.)

Cough A

Phlegm/Sputum B

Chest tightness C

Wheeze D

Shortness of breath E

Some other symptom F

No single symptom was most bothersome G

[IF Q23=B AND Q24=B AND Q25=A]

[RADIO BUTTONS]

Single Punch Answer

Q28C. About how long did these episodes last on average?

Less than an hour A

One to a few hours B

All day or night C

Continuing for the next 1 or 2 days D

Continuing for the next 3 days or longer E

[IF Q23=B AND Q24=B AND Q25=A]

[RADIO BUTTONS]

Single Punch Answer

Q29C. During episodes like this, did your child use a rescue inhaler more than he or she would on days when asthma symptoms were less bothersome?

Yes A

No B

[CONTINUE WITH Q30.]

Q30. Please recall a day when asthma symptoms caused your child discomfort or bother, but did not really interfere with his or her activities or sleep. On a typical day like that during the past year, which of the following symptoms did your child experience? (Please select all that apply.)

Cough A

Phlegm/Sputum B

Chest tightness C

Wheeze D

Shortness of breath E

Other symptoms F

[RADIO BUTTONS]

Single Punch Answer

Q31. Which of those symptoms was the most bothersome? (Please choose one answer.)

Cough A

Phlegm/Sputum B

Chest tightness C

Wheeze D

Shortness of breath E

Some other symptom F

No single symptom was most bothersome G

[RADIO BUTTONS]

Single Punch Answer

Q32. When asthma symptoms caused discomfort or bother, but did not interfere with your child’s activities or sleep, about how long did these episodes last on average?

Less than an hour A

One to a few hours B

All day or night C

Continuing for the next 1 or 2 days D

Continuing for the next 3 days or longer E

[RADIO BUTTONS]

Single Punch Answer

Q33. During episodes like this, did your child use a rescue inhaler more than he or she would on days when asthma symptoms were less bothersome?

Yes A

No B

[All respondents get Q34.]

Suppose that the doctor who treats your child’s asthma told you about a new asthma medication. The new drug would be taken daily by inhaler, and would help reduce the total number of days when asthma symptoms cause your child discomfort or bother.

These two paragraphs for those currently taking daily medication: [Yes to Q16 OR Q17]

The new medication would be similar to any inhaled “preventer” medications your child now takes daily for long-term control of asthma. It would provide the same benefits as these drugs, but it would be more effective at reducing the number of days when asthma symptoms bother your child.

The taste and smell of the new drug would be similar to inhaled medications your child currently uses. It would be taken on the same time schedule. The new drug would be as safe as the asthma medications your child now takes, and would have similar side effects. Any side effects your child experiences from current drugs would probably occur with the new drug as well. If your child has no side effects from current drugs, you should expect that he/she would not have any with the new drug.

These two paragraphs for those not taking daily medications [No Q16 AND Q17]

The new medication would be similar to inhaled “preventer” medications that some people with asthma now take daily for long-term control of asthma. It would provide the same benefits as these drugs, but it would be more effective at reducing the number of days when asthma symptoms bother your child.

Also, the new drug would be safer with fewer side effects than the daily medications that some people with asthma currently use. Only a very small fraction of patients would experience any side effects at all, and these effects would be very minor. It would require only about a minute to take the new drug as directed once daily.

And everyone gets the rest…

In clinical trials, the new drug has proven safe and effective in reducing the number of days that asthma symptoms cause discomfort or bother. If your child used the new drug, you should expect that he or she would have X fewer days per year when asthma symptoms caused your child discomfort or bother.

[Compute X = a * ndaysyr. If this formula does not produce an integer, round UP to the nearest integer. Assign a from {.05, .10, .20, .40, .50, .60, .70, .80, .90, .95}.]

The new drug would only reduce the total number of days that asthma symptoms bothered your child. It would not affect the severity of any symptoms that cause discomfort or bother.

The display shows the number of asthma symptom days your child had during the past year, and the reduction in days that your child would experience from using the new drug.

[DISPLAY] A bar chart with one vertical bar.

• Total height of bar = NDAYSYR.

• Bottom segment = GREEN: Height = Residual of [NDAYSYR – X].

• Top segment = BLACK: Height = X.

The new drug is designed to replace any inhaled medications your child now takes daily for long-term control of asthma. However, this drug would be covered differently by insurance and health plans. Based on your answers about health insurance and drug costs, the new drug would cost you $Y more per year than you currently spend on inhaled medications for long-term control of your child’s asthma. This would be your out-of-pocket expense. So if you bought the new drug you child would have $Y less per year to spend for buying other things.

[RADIO BUTTONS]

Single Punch Answer

Q34. Would you be willing to pay $Y per year for this drug, to reduce the number of days that asthma symptoms cause your child discomfort or bother by X per year?

Yes A

No B

[IF Q34 = A  ASK Q34A.

ELSE IF Q34 = B  ASK Q34B.]

[IF Q34=A]

[RADIO BUTTONS]

Single Punch Answer

Q34A. Would you be willing to pay $YUP per year for this drug, to reduce the number of days that asthma symptoms cause your child discomfort or bother by X per year?

Yes A

No B

[IF Q34=B]

[RADIO BUTTONS]

Single Punch Answer

Q34B. Would you be willing to pay $YDOWN per year for this drug, to reduce the number of days that asthma symptoms cause your child discomfort or bother by X per year?

Yes A

No B

Assign Y, YUP and YDOWN from:

Y (Q34)	YUP (Q34A)	YDOWN (Q34B)

[IF Q34B = B  ASK Q34C.

ELSE ASK Q34D.]

[IF Q34B=B]

Q34C. Which of the following best describes why you would not buy the new medication? (Please select all that apply.)

The new drug does is not effective enough A

The new drug is too expensive B

I should not have to pay for medicine C

I am concerned about possible side effects from the new drug D

The new drug is not much better than current drugs E

The new drug would not really work as claimed F

I need more information about the new drug G

I do not need the new drug H

I’m not that worried about reducing days when asthma symptoms bother me I

I already do enough to control my asthma J

Other reasons K

Q34D. Which of the following best describes why you would buy the new medication? (Please select all that apply.)

The new drug does is more effective than current drugs A

The new drug is worth the cost B

When it comes to my asthma, I don’t care about cost C

It’s important to me to reduce the number of days when asthma symptoms bother me D

Other reasons E

Earlier in the survey, you rated your child’s overall health with asthma as [insert answer to Q7] on a scale of 0 to 100. Also, you indicated that your child’s health without asthma would be [insert answer to Q8] on a scale of 0 to 100. Recall that on this scale, 0 means death and 100 means perfect health. Please think about how you would rate your child’s health if your child used the new drug and reduced your child’s asthma symptom days by X per year.

Q34E. Suppose that your child did use the new drug, and it reduced the number of days that asthma symptoms cause your child discomfort or bother by X per year. How would you rate your child’s health on the 0 to 100 scale?

[Bring up the display with the previous answers still shown. Again the respondent enters a number in the box. “Your child’s health with your child’s asthma” is indicated next to the first answer [Q7]. “Your child’s health without asthma” is indicated next to the second answer [Q8]. The respondent now enters a new number in the box.

Now suppose that instead of the drug just described, your child’s doctor told you about a different new drug.

[IF Q23 = B AND Q24 = B AND Q25 = B  ASK Q35.

ELSE IF Q23 = A OR Q24 = A OR Q25 = A  SKIP TO Q36.]

(Note: Respondents get Q36 IF: Q23=B AND Q24=B AND Q25=B.)

Insert second WTP question for those without any bad days.

(Note: Respondents get Q36 IF: Q23=A or Q24=A or Q25=a.)

Unlike the drug just described, this medication would not reduce the number of days when your child’s asthma symptoms cause discomfort or bother. But it would help relieve your child’s symptoms on the days when your the symptoms are the most bothersome.

The new medication would be similar to the “rescue” inhaler your child currently uses to relieve asthma symptoms. It would provide all of the same benefits as your child’s current quick-relief medication. But the new drug would be more effective at relieving asthma symptoms when they are the most bothersome.

The taste and smell of the new drug would be similar to inhaled medications currently used. It would be taken in the same way. The new drug would be as safe as the asthma medications your child now takes, and would have similar side effects. Any side effects your child experiences from current drugs would probably occur with the new drug as well. If your child has no side effects from current drugs, you should expect the he or she would not have any with the new drug.

In clinical trials, the new drug has proven as safe and effective as current “rescue” medications. But the new drug has proven more effective at relieving asthma symptoms when they are the most bothersome

[IF Q23 = A:]

If your child used the new drug, you should expect that he or she would have W fewer days per year when asthma symptoms cause your child to visit an emergency room, hospital, health clinic or doctor’s office, or to stay overnight in a hospital.

[Compute W = b * nsevere. If this formula does not produce an integer, round UP to the nearest integer. Assign b from {.05, .10, .20, .40, .50, .60, .70, .80, .90, .95}.]

[ELSE IF Q23 = B and Q24 = A:]

If your child used the new drug, you should expect that he or she would have W fewer days per year when asthma symptoms interfere with most of your child’s activities, or awaken your child at night or significantly disturb his/her sleep, or cause your child to leave school, or to stay home, or cause someone to telephone a doctor or nurse.

[Compute W = b * nbad. If this formula does not produce an integer, round UP to the nearest integer. Assign b from {.05, .10, .20, .40, .50, .60, .70, .80, .90, .95}.]

[ELSE IF Q23 = B and Q24 = B and Q25 = A:]

If your child used the new drug, you should expect that he or she would have W fewer day per year when asthma symptoms interfere somewhat with your child’s activities or sleep.

[Compute W = b * nmod. If this formula does not produce an integer, round UP to the nearest integer. Assign b from {.05, .10, .20, .40, .50, .60, .70, .80, .90, .95}.]

[END IF]

On the W days your child’s asthma symptoms would still be present and bothersome, but would not interfere with activities. The total number of days that your child’s asthma symptoms cause discomfort or bother would not be affected by switching from your child’s current rescue inhaler to the new drug.

The display shows the number of asthma symptom days your child had during the past year, and the number that would occur if your child used the new drug.

[DISPLAY] A bar chart with one vertical bar.

Starting point for chart is as follows:

• Total height of bar = NDAYSYR.

• Bottom segment = GREEN: Height = Residual of [NDAYSYR – NSEVERE – NBAD – NMOD].

• Next segment = YELLOW: Height = NMOD, IF NMOD > 0.

• Next segment = ORANGE: Height = NBAD, IF NBAD > 0.

• Next segment = RED: Height = NSEVERE, IF NSEVERE > 0.

Then, take the top segment and the top W units BLACK, to show the reduction.

The new drug is designed to replace any rescue inhaler your child now uses. However, this drug would be covered differently by insurance and health plans. Based on your answers about health insurance and drug costs, the new drug would cost you $Z more per year than you child currently spend on any rescue inhaler your child currently uses. This would be your out-of-pocket expense. So if you bought the new drug you would have $Z less per year to spend for buying other things.

[RADIO BUTTONS]

Single Punch Answer

Q36. Would you be willing to pay $Z per year for this drug, to reduce the number of days when your child’s asthma symptoms are most bothersome by W per year?

Yes A

No B

[IF Q36 = A  ASK Q36A.

ELSE IF Q36 = B  ASK Q36B.]

[IF Q36=A]

[RADIO BUTTONS]

Single Punch Answer

Q36A. Would you be willing to pay $ZUP per year for this drug, to reduce the number of days when your child’s asthma symptoms are most bothersome by W per year?

Yes A

No B

[IF Q36=B]

[RADIO BUTTONS]

Single Punch Answer

Q36B. Would you be willing to pay $ZDOWN per year for this drug, to reduce the number of days when your child’s asthma symptoms are most bothersome by W per year?

Yes A

No B

Assign Z, ZUP and ZDOWN from:

Z (Q36)	ZUP (Q36A)	ZDOWN (Q36B)

[IF Q36B = B  ASK Q36C.

ELSE ASK Q36D.]

[IF Q36B=B]

Q36C. Which of the following best describes why you would not buy the new medication? (Please select all that apply.)

The new drug does is not effective enough A

The new drug is too expensive B

I should not have to pay for medicine C

I am concerned about possible side effects from the new drug D

The new drug is not much better than current drugs E

The new drug would not really work as claimed F

I need more information about the new drug G

I do not need the new drug H

I’m not that worried about reducing days when asthma symptoms bother me I

I already do enough to control my asthma J

Other reasons K

Q36D. Which of the following best describes why you would buy the new medication? (Please select all that apply.)

The new drug does is more effective than current drugs A

The new drug is worth the cost B

When it comes to my asthma, I don’t care about cost C

It’s important to me to reduce the days when my asthma symptoms are most bothersome D

Other reasons E

Earlier in the survey, you rated your child’s overall health with asthma as [insert answer to Q7] on a scale of 0 to 100. Also, you indicated that your child’s health without asthma would be [insert answer to Q8] on a scale of 0 to 100. Recall that on this scale, 0 means death and 100 means perfect health. Please think about how you would rate your child’s health if your child used the new drug and reduced the number of days that asthma symptoms are most bothersome by W per year.

Q36E. Suppose that your child did use the new drug, and it reduced the number of days that your child’s asthma symptoms are most bothersome by W per year. How would you rate your child’s health on the 0 to 100 scale?

[Bring up the display with the original two answers still shown. Again the respondent enters a number in the box. “Your child’s health with your child’s asthma” is indicated next to the first answer [Q7]. “Your child’s health without asthma” is indicated next to the second answer [Q8]. The respondent now enters a new number in the box.

We have just a few final questions about your child’s asthma…

[RADIO BUTTONS]

Single Punch Answer

Q40. Does your child’s asthma limit the amount or kind of work your child could do at school?

Yes A

No B

[RADIO BUTTONS]

Single Punch Answer

Q41. Does asthma limit your child’s ability to do household chores?

Yes A

No B

[RADIO BUTTONS]

Single Punch Answer

Q42. Has a doctor or health professional ever given you and/or your child written instructions for monitoring and controlling your child’s asthma?

Yes A

No B

[RADIO BUTTONS]

Single Punch Answer

Q43. Does your child have a peak flow meter (a device that measures how much air your child can blow out of his or her lungs)?

Yes A

No B

[IF Q43 = A]

[RADIO BUTTONS]

Single Punch Answer

Q43A. How often does your child use it?

(Answer options are…)

[RADIO BUTTONS]

Single Punch Answer

Q44. Besides using a peak flow meter and monitoring your child’s asthma symptoms, do you or your child do anything else to give advance warning of when your child’s asthma might be getting worse?

Yes A

No B

Q45. The following questions are about some activities and items in the home that may affect the symptoms some people with asthma experience. Please answer each question.

	No	Yes	Don’t Know
Does your child use a mattress cover that is made especially for controlling dust mites?
Does your child use a pillow cover that is made especially for controlling dust mites?
Are your child’s bed sheets and pillowcases washed in hot water?
Is there carpeting or rugs in your child’s bedroom?
Are any pets, like dogs, cats, hamsters, birds or other furry or feathered pets allowed in your child’s bedroom?
Are any furry or feathered pets that are allowed inside your home?
During the past 12 months, has anyone seen cockroaches inside your home?
Is an air cleaner or purifier used regularly inside your home?
Is a dehumidifier regularly used to reduce moisture inside your home?
During the past 12 months, has anyone smoked inside your home?
Is a fireplace or wood-burning stove used in your home?
Is gas used for cooking in your home?
During the past 12 months, has anyone seen or smelled mold or a musty odor in your home?
Does your child ever work or play hard outdoors when pollen or air pollution levels are high?
Does your child ever work or play hard outdoors during cold and windy weather?

[IF SAMVAR HEAL1700 IS NULL]

[RADIO BUTTONS]

Single Punch Answer

Q46. Do you smoke cigarettes?

Yes ................................................................... 1

No..................................................................... 2

End of survey: Thank your child for completing this survey.

Page 30 Last saved: 2/23/2007 1:25 PM