1 Survey

OMB#: 0925-New

EXP: XX/XXX

Attachment 1

Children’s Heart Health Promotion Tracker

Burden Disclosure Statement

Public reporting burden for this collection of information is estimated to average 8 minutes per response, including time for reviewing instructions and completing the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-XXX).

[ENSURE THAT PARENTS WITH MULTIPLE CHILDREN ANSWER FOR ONLY ONE CHILD –SPECIFY AGE BETWEEN 0-7]

1. What preventable adult health problems can start in childhood? Please type as many as come to mind. OPEN ENDED

1a. Which, if any, of the following diseases do you believe can be prevented by things you do now while your child is young? (Select all the apply) (Randomize)

1. Asthma

2. Diabetes

3. Obesity

4. Heart Disease

5. Glaucoma

6. Alzheimer's

7. Arthritis

8. Other (please specify) OPEN ENDED

1b. Please indicate how much you believe you can impact your child’s current risk for getting each of the following conditions in the future. (Matrix: a lot, a little or not at all; allow for Don’t Know) (Randomize, Select one for each)

1. Asthma

2. Diabetes

3. Obesity

4. Heart Disease

5. Glaucoma

6. Alzheimer's

7. Arthritis

2. At what age do you think risks for heart disease can first develop? (Select one)

1. 0-7 years old

2. 8-15 years old

3. 15-25 years old

4. 25-40 years old

5. 40-55 years old

6. 55+ years old

7. Don’t know (Go to Q4)

3. From which of the following sources did you learn about when risks of heart disease can first develop? (Select all that apply) (Randomize)

1. Your doctor

2. Your child’s doctor

3. TV

4. Magazine

5. Internet

6. Friend or Family Member

7. Direct Mail

8. Radio

9. Other (please specify) OPEN ENDED

4. How much do you think each of the following can help prevent heart disease later in your child’s life? (a lot, a little, not much, not at all.) (Randomize, Select all that apply)

1. Providing your child with a non-smoking home

2. Encouraging physical activity daily for your child

3. Feeding your child a nutritious diet (including fruits, vegetables, and whole grains, that is low in saturated fat and added sugars)

4. Maintaining a healthy weight for your child

5. Making sure your child drinks water regularly

6. Limiting how much juice and soda your child drinks

7. Getting your child immunized

8. Limiting your child’s time in front of the television/computer

9. Other (please specify) OPEN ENDED

5. Approximately how many times have you taken your child to a primary care doctor (pediatrician, family doctor) in the past year? (Select one)

1. Once

2. 2-3 times

3. 4-7 times

4. More than 7 times

5. None (Go to Q8)

6. During any of these visits, did you have a conversation with your child’s doctor on any of the following topics pertaining to your child’s health and development? (Select all that apply) (Randomize)

1. Growth milestones

2. Nutrition

3. Day-to-day health concerns

4. Risk for obesity

5. Risk for diabetes

6. Risk for heart disease (IF ANSWER YES, AFTER COMPLETING THE QUESTION, GO TO Q7. ALL OTHERS SKIP TO Q8)

7. Height

8. Weight

9. Hearing

10. Sight

11. Immunizations

12. Other (please specify) OPEN ENDED

7. Do you recall who initiated the conversation about how to prevent your child’s risk for future heart disease? (Select One)

1. You initiated (Go to 7a)

2. Your child’s doctor initiated (Go to 7b)

7a. From which of the following sources did you read, hear or see something that prompted you to have a conversation about how to prevent your child’s risk for future heart disease? (Randomize, Select all that apply)

1. TV news report

2. TV advertisement

3. Newspaper article

4. Newspaper ad

5. Magazine article

6. Magazine ad

7. Internet article or information

8. Internet ad

9. Community

10. Family/ Friend/ Word of Mouth

11. Family History

12. Other (please specify) OPEN ENDED

7b. When did you last have a conversation about how to prevent your child’s risk for future heart disease with your child’s doctor? (Select one)

1. Past three months

2. Past 6 months

3. Past year

4. Over a year ago

5. Don’t remember

6. Never

7c. During this discussion on your child’s risk for future heart disease, which, if any, of the following areas were specifically addressed? (Select all that apply) (Randomize)

1. Family heart history

2. Providing a smoke-free household

3. Diet/Nutrition

4. Height to Weight Ratio (BMI) tracking

5. Blood Pressure

6. Cholesterol Levels

7. Physical Activity

8. None of these

9. Don’t recall

8. Is your home a non-smoking environment? (Select one)

1. Yes (Go to 8a)

2. No (Go to 9)

8a. Has your household become a non-smoking environment in the past year? (Select one)

1. Yes (Go to 8b)

2. No, it was non-smoking before that (Go to 9)

8b. Why did your home become a non-smoking environment in the past year? (Randomize, Select as many as apply)

1. Talked with doctor about effects on my health

2. Talked with doctor about effects on my child’s health

3. The smoke bothered my family

4. I was worried about my child’s health

5. The smoke worsens a condition my child has, like asthma

6. Ads on heart health

7. School Programs

8. News Reports/Articles about dangers of smoking/secondhand smoke

9. Other

9. How many hours a week does your child engage in moderate to vigorous physical activity (for example, brisk walking, running, bicycling, dancing, physical play, etc)? (Select one)

1. 0 hours

2. 1-2 hours

3. 3-4 hours

4. 5-6 hours

5. 7 or more hours

9a. Has your child engaged in more, less, or the same level of physical activity in the past year? (Select One)

1. More

2. The same amount

3. Less

9b. Have you been involved in trying to have your child participate in more physical activity (for example, organized sports, walking, dancing)? (Select One)

1. Yes (Go to 9c)

2. No (Go to 10)

9c. Why were you involved with trying to have your child participate in more physical activity? (Randomize, Select as many as apply)

1. Talked with Child’s Doctor

2. Ads on heart health

3. School Programs

4. News Reports/Articles

5. General interest in child’s health

6. My child is overweight

7. My child spends a lot of time doing sedentary activities, like watching TV

8. My child needs an outlet for his/her energy

9. Other

10. Do you know what a BMI calculation is?

1. Yes

2. No

10a. Has your child ever had his/her BMI calculated (i.e., a number calculated from the child’s height and weight measures that can be mapped on a chart to show the percentile compared to children who are the same age and sex)?

1. Yes (Go to 10b)

2. No (Go to 10e)

3. Don’t know (Go to 10e)

10b. Has your child’s BMI been calculated in the last year?

1. Yes (Go to 10c)

2. No (Go to 10e)

3. Don’t know (Go to 10c)

10c. When your child’s BMI was last measured, was it within the healthy range?

1. Yes, it is within healthy range (Go to 10e)

2. No, it is not within healthy range (Go to 10d)

3. I don’t know (Go to 10e)

10d. What changes (if any) are you making to get your child’s BMI into the healthy range? Please be as detailed as possible. OPEN ENDED

10e. For which of the following reasons do you believe doctors measure a child’s BMI? (Select as many as apply)

1. More accurate measure of if a child is overweight or obese

2. Compares a child to others of the same age and sex

3. Determines if a child is at risk for health conditions like diabetes

4. Helps identify if a child has nutritional deficiencies

5. Identifies any growth abnormalities

6. Don’t know

11. Is there is a history of heart disease in your family?

1. Yes

2. No

3. Don’t know

11a. Have you ever discussed your family’s history of heart disease with your child’s doctor?

1. Yes (go to 11b)

2. No (go to 12)

11b. Have you discussed your family’s heart disease history with your child’s doctor in the past year?

1. Yes (go to 11c)

2. No (go to 12)

11c. Why did you discuss your family’s heart disease history with your child’s doctor? (Select as many as apply)

1. Doctor brought it up

2. Ads on heart health

3. School Programs

4. News Reports/Articles

5. Family member has heart disease

6. Another child has a heart disease

7. Other

12. Has your child had an assessment of his/her heart health (a typical assessment, depending on a child’s age, may include taking blood pressure, checking blood cholesterol, checking for diabetes, asking about family history of heart problems, tracking BMI, asking about physical activity, and asking about exposure to smoking)?

1. Yes (Go to 12a)

2. No (Go to 13)

12a. Why did your child have an assessment of her/her heart health?

1. I asked for it (Go to 12b)

2. The doctor recommended it (Go to 13)

12b. Did you ask for an assessment of your child’s heart health within the past year?

1. Yes (Go to 12c)

2. No, I had asked for this assessment to be done in the past (Go to 13)

12c. Why did you ask for your child’s doctor to assess his/her heart health? (Select as many as apply)

1. Previous discussion with doctor

2. Ads on heart health

3. School Programs

4. News Reports/Articles

5. Other

13. Do you know of any specific campaigns or programs about children’s health?

1. Yes (go to 13a)

2. No (Go to 14)

13a. Did any of the specific campaigns or programs focus on the following children’s health areas? (Select as many as apply)

1. Childhood Diabetes

2. Child Heart Health

3. Childhood Asthma

4. Childhood Obesity

5. Pediatric Arthritis

6. Child Smoking Issue Campaign

7. Other

13b. Do you recall the name of the campaign(s) or program? (please specify)

OPEN ENDED

14. Please indicate whether you agree or disagree with each of the following statements (agree a lot, agree a little, disagree a little, disagree a lot).

1. I wish I knew more about the steps I can take now to help prevent my child from getting heart disease in the future

2. I wish I knew more about the risk factors in children that can lead to adult heart disease

3. I believe the risk of heart disease begins developing in childhood

4. As a parent, there are steps you can take to help prevent your child from getting heart disease in the future

5. When visiting my child’s doctor, he/she rarely speaks to me about the prevention of heart disease

6. When visiting my child’s doctor, I rarely ask about heart disease

13