Form Approved
OMB No. 0920-xxxx
Exp. Date xx/xx/xxxx
Health and Media Survey
Public reporting burden of this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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 CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx)
SECTION A: PHYSICAL ACTIVITY AND NUTRITION
Think about all the vigorous activities which take hard physical effort that you did in the last 7 days. Vigorous activities make you breathe harder than normal and may include heavy lifting, aerobics, or fast bicycling. Think only about those physical activities that you did for at least 10 minutes at a time.
During the last 7 days, on how many days did you do vigorous physical activities?
None
1 Day
2 Days
3 Days
4 Days
5 Days
6 Days
7 Days
Rationale: Physical activity behavior; Source: International Physical Activity Questionnaire
How much time did you usually spend doing vigorous physical activities on any one of those days?
_____hours/minutes per day
Rationale: Physical activity behavior; Source: International Physical Activity Questionnaire
Think about the activities which take moderate physical effort that you did in the last 7 days. Moderate physical activity make you breathe somewhat harder than normal and may include carrying light loads, bicycling at a regular pace, or housework. Do not include walking. Again, think about only those physical activities that you did for at least 10 minutes.
During the last 7 days, on how many days did you do moderate physical activities?
None
1 Day
2 Days
3 Days
4 Days
5 Days
6 Days
7 Days
Rationale: Physical activity behavior; Source: International Physical Activity Questionnaire
How much time did you usually spend doing moderate physical activities on any one of those days?
_____hours/minutes per day
Rationale: Physical activity behavior; Source: International Physical Activity Questionnaire
Now think about the time you spent walking in the last 7 days. This includes at work and at home, walking to travel from place to place, and any other walking that you might do solely for recreation, sport, exercise, or leisure.
During the last 7 days, on how many days did you walk for at least 10 minutes at a time?
None
1 Day
2 Days
3 Days
4 Days
5 Days
6 Days
7 Days
Rationale: Physical activity behavior; Source: International Physical Activity Questionnaire
How much time did you usually spend walking on any one of those days?
_____hours/minutes per day
Rationale: Physical activity behavior; Source: International Physical Activity Questionnaire
Would you say that you usually get enough physical activity?
Yes
No
Rationale: Physical activity behavior; Source: new item
What do you usually do when you have a choice about how you spend leisure time?
Almost always choose activities like TV, reading, listening to music, or computers.
Usually choose activities like TV, reading, listening to music, or computers.
Just as likely choose active or inactive activities.
Usually choose activities like walking, bicycling, dancing, or active sports.
Almost always choose activities like walking, bicycling, dancing, or active sports.
Rationale: Physical activity/sedentary behavior; Source: PACE questionnaire (Beresford et al, 2007)
Fruits and vegetables come in many forms: fresh, frozen, canned, dried, and 100% fruit and vegetable juices. Fruits and vegetables can be cooked or eaten raw. They can also be eaten by themselves or as part of a mixed dish such as soups or casseroles. Use this table to help you count your fruit and vegetable servings... |
COUNT AS ONE SERVING: Vegetables: 1/2 cup of cooked or raw vegetables 1 cup of raw leafy greens
Fruit: 1/2 cup or a medium sized piece of fruit 3/4 cup of 100% fruit juice 1/4 cup of dried fruit |
How many servings of fruits and vegetables do you usually eat each day?
None
1 Serving
2 Servings
3 Servings
4 Servings
5 Servings
6 Servings or more
Rationale: Fruit and vegetable consumption; Source: PACE questionnaire (Beresford et al, 2007)
Would you say that you usually get enough servings fruits and vegetables?
Yes
No
Rationale: fruit and vegetable consumption; Source: new item
Do you consistently choose to eat high fiber foods such as high fiber cereals (5 grams/serving), breads (2 grams per serving), beans and legumes, fruits, and vegetables?
No, and I do NOT intend to in the next 6 months.
No, but I intend to in the next 6 months.
No, but I intend to in the next 30 days.
Yes, I have been, but for LESS than 6 months.
Yes, I have been for MORE than 6 months.
Rationale: Dietary fiber consumption/intentions; Source: PACE questionnaire (Beresford et al, 2007)
Do you consistently avoid eating high fat foods?
1. No, and I do NOT intend to in the next 6 months.
2. No, but I intend to in the next 6 months.
3. No, but I intend to in the next 30 days.
4. Yes, I have been, but for LESS than 6 months.
5. Yes, I have been for MORE than 6 months.
Rationale: High fat food avoidance behavior; Source: PACE questionnaire (Beresford et al, 2007)
About how often do you drink regular soda or pop that contains sugar? Do not include diet soda or diet pop.
_____times per ______day/week/month
Never
Rationale: Sugar-sweetened beverage consumption; Source: 2011 BRFSS
About how often do you drink sweetened fruit drinks, such as Kool-aid, cranberry, and lemonade? Include fruit drinks you made at home and added sugar to.
_____times per ______day/week/month
Never
Rationale: Sugar-sweetened beverage consumption; Source: 2011 BRFSS
On how many of the past 7 days did you eat food from a fast-food restaurant, such as McDonalds, KFC, Pizza Hut, Taco Bell, or a local fast-food restaurant?
Zero days
One day
Two days
Three days
Four days
Five days
Six days
Seven days
Rationale: Fast-food consumption; Source: CKG! Healthy Living Awareness Survey
|
No, and I don't intend to in the next 6 months |
Yes, and I intend to in the next 6 months |
Yes, and I intend to in the next 30 days |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Rationale: Intentions related to physical activity, nutrition, sugar-sweetened beverage consumption, and fast food consumption; Source: Adapted from PACE questionnaire (Beresford et al, 2007)
Please indicate how likely you are to do each of the following in the next six months. In the next six months how likely are you to…
Look for more information on ways to make it easier for you and your family to get healthy foods and drinks
1. Very unlikely
2. Somewhat unlikely
3. Neither likely nor unlikely
4. Somewhat likely
5. Very likely
Rationale: Intentions to seek out information on healthy foods and drink; Source: Fall 2011 HealthStyles Survey (CDC)
Look for more information on ways to make it easier for you and your family to be active and do things like walk, bike, and play
1. Very unlikely
2. Somewhat unlikely
3. Neither likely nor unlikely
4. Somewhat likely
5. Very likely
Rationale: Intentions to seek out information on ways to be more physically active; Source: Fall 2011 HealthStyles Survey (CDC)
Support policies or other efforts in your community that make it easier for people in your community to get healthy foods and drinks
1. Very unlikely
2. Somewhat unlikely
3. Neither likely nor unlikely
4. Somewhat likely
5. Very likely
Rationale: Intentions to support community-based efforts to increase healthy food and drink access; Source: Adapted from Fall 2011 HealthStyles Survey (CDC)
Support policies or other efforts in your community that make it easier for people in your community to be active and do things like walk, bike, and play
1. Very unlikely
2. Somewhat unlikely
3. Neither likely nor unlikely
4. Somewhat likely
5. Very likely
Rationale: Intentions to support community-based efforts to increase access to physical activity resources; Source: Adapted from Fall 2011 HealthStyles Survey (CDC)
SECTION B: ATTITUDES ABOUT HEALTH
The next few questions ask about your community. Different people think about community in different ways. Community can be people in your town, neighborhood, place of worship, or local organization. How much do you agree or disagree with each of the following statements?
Childhood obesity is a problem in my community.
1. Strongly disagree
2. Somewhat disagree
3. Neither agree nor disagree
4. Somewhat agree
5. Strongly agree
Rationale: Awareness of childhood obesity; Source: Fall 2011 HealthStyles Survey (CDC)
Adult obesity is a problem in my community.
1. Strongly disagree
2. Somewhat disagree
3. Neither agree nor disagree
4. Somewhat agree
5. Strongly agree
Rationale: Awareness of adult obesity; Source: Fall 2011 HealthStyles Survey (CDC)
Children not getting enough healthy foods and drinks is a problem in my community.
1. Strongly disagree
2. Somewhat disagree
3. Neither agree nor disagree
4. Somewhat agree
5. Strongly agree
Rationale: Awareness of risk behaviors associated with childhood obesity; Source: Fall 2011 HealthStyles Survey (CDC)
Children not having access to places to be active and do things like walk, bike, and play is a problem in my community.
1. Strongly disagree
2. Somewhat disagree
3. Neither agree nor disagree
4. Somewhat agree
5. Strongly agree
Rationale: Awareness of risk behaviors associated with childhood obesity; Source: Fall 2011 HealthStyles Survey (CDC)
How much do you agree or disagree with each of the following statements?
It is important for me to eat healthy foods.
1. Strongly disagree
2. Somewhat disagree
3. Neither agree nor disagree
4. Somewhat agree
5. Strongly agree
Rationale: Attitudes about individual healthy eating behavior; Source: New item
It is important for me to drink healthy drinks such as water, milk, or 100% fruit juice.
1. Strongly disagree
2. Somewhat disagree
3. Neither agree nor disagree
4. Somewhat agree
5. Strongly agree
Rationale: Attitudes about individual healthy drinking behavior; Source: New item
It is important for me to avoid non-diet sugar-sweetened drinks (For example, Coke, Kool-Aid, Snapple, Gatorade).
1. Strongly disagree
2. Somewhat disagree
3. Neither agree nor disagree
4. Somewhat agree
5. Strongly agree
Rationale: Attitudes about individual healthy drinking behavior; Source: New item
[ASK IF S2 >= 1] It is important for me to keep my children from drinking non-diet sugar-sweetened drinks (For example, Coke, Kool-Aid, Snapple, Gatorade).
1. Strongly disagree
2. Somewhat disagree
3. Neither agree nor disagree
4. Somewhat agree
5. Strongly agree
Rationale: Attitudes about children’s healthy drinking behavior; Source: New item
It is important for me to be active and do things like walk, bike and play.
1. Strongly disagree
2. Somewhat disagree
3. Neither agree nor disagree
4. Somewhat agree
5. Strongly agree
Rationale: Attitudes about physical activity; Source: New item
[ASK IF S2 >= 1] It is important for me to get my children to be active and do things like walk, bike and play.
1. Strongly disagree
2. Somewhat disagree
3. Neither agree nor disagree
4. Somewhat agree
5. Strongly agree
Rationale: Attitudes about children’s physical activity; Source: New item
There are different ideas about what causes people to be overweight. To what extent does each of the following cause people to be overweight?
Genetics or heredity (something that tends to run in families)
1. Not at all
2. A little
3. Somewhat
4. A lot
Rationale: Beliefs about causes of overweight; Source: Fall 2011 HealthStyles Survey (CDC)
Drinking sugary drinks like soda, not diet drinks or 100% fruit juice
1. Not at all
2. A little
3. Somewhat
4. A lot
Rationale: Beliefs about causes of overweight; Source: Fall 2011 HealthStyles Survey (CDC)
Eating fast food like burgers and fries
1. Not at all
2. A little
3. Somewhat
4. A lot
Rationale: Beliefs about causes of overweight; Source: Fall 2011 HealthStyles Survey (CDC)
Not getting enough physical activity or exercise
1. Not at all
2. A little
3. Somewhat
4. A lot
Rationale: Beliefs about causes of overweight; Source: Fall 2011 HealthStyles Survey (CDC)
SECTION C: MEDIA USE AND AWARENESS
On an average day, how much television do you watch?
None
Less than one hour
About 1 hour
About 2 hours
About 3 hours
About 4 hours
5 hours or more
Rationale: use of television; Source: FL Online Adult Longitudinal Media Survey
On an average day, how many hours do you listen to the radio?
None
Less than one hour
About 1 hour
About 2 hours
About 3 hours
About 4 hours
5 hours or more
Rationale: use of radio; Source: FL Online Adult Longitudinal Media Survey
On an average day, how many hours do you use the Internet for personal reasons?
None
Less than one hour
About 1 hour
About 2 hours
About 3 hours
About 4 hours
5 hours or more
Rationale: use of internet; Source: FL Online Adult Longitudinal Media Survey
What type of Internet connection do you have for your home computer or other primary computer?
Cable/DSL/Broadband/High-Speed
Dial-Up
My computer is not connected to the internet
Not sure
Rationale: ability to view ads online; Source: NY Media Tracking Survey Online
In the past 30 days have you seen, heard, or read any TV, radio, newspaper, or online advertising or messages about any of the following? Please select all that apply.
Encouraging individuals to eat healthy food
Encouraging individuals to drink healthy drinks (water, milk, 100% fruit juice)
Encouraging individuals to get physical activity
Increasing local healthy food and drink options
Increasing local physical activity options
Making it easier in communities to walk, bike, and play
Getting more physical education and physical activity for children in schools
Making it easier for children to drink more water throughout the day
None of these
Rationale: Awareness of NPAO-related media campaigns; Source: Fall 2011 HealthStyles Survey (CDC)
In the past 30 days, how often have you seen or heard any advertising or messages that encourage individuals to eat healthy foods, drink healthy beverages, and/or be physically active?
1. Not at all
2. Once in the past 30 days
3. A few times in the past 30 days
4. Many times in the past 30 days
5. Daily or almost daily in the past 30 days
6. Don’t know
Rationale: Frequency of exposure to NPAO-related media campaigns; Source: Adapted from Fall 2011 HealthStyles Survey (CDC)
Thinking of the messages that you saw or heard that encouraged individuals to eat healthy foods, drink healthy beverages, and/or be physically active, where did you see or hear them? Please select all that apply.
Newspapers or magazines
Billboards or posters
TV or radio
Websites
Online ads
Promotion at work
Promotion at a sports or community event
Somewhere else not listed
Don’t remember
Rationale: Source of exposure to NPAO-related media campaigns; Source: Fall 2011 HealthStyles Survey (CDC)
Now, we would like you to view a series of television advertisements that have been shown in the U.S. When you are ready, please click on the link below to view the first advertisement. There are a total of XX ads to view. After you view each ad, there will be a few questions that ask about your opinions of the ad.
[randomize order of ads]
[record order]
[SHOW AD #1]
Were you able to view this video?
Yes
No
[if C8=no, skip to C10]
Rationale: exposure to ad; Source: FL Online Adult Longitudinal Media Survey
As you viewed this ad, how was it in terms of viewing and sound quality? In answering, think about such issues as whether the images were jerky or unclear or whether the sound was clear and smooth.
Not at all clear and smooth
Somewhat clear and smooth
Clear and smooth
Very clear and smooth
Extremely clear and smooth
Rationale: clear exposure to ad; Source: NY Media Tracking Survey Online
[ASK C10 ONLY IF C8 = NO]
Now we would like to show you some screen shots from a television advertisement that has been shown in the U.S. Once you have viewed the images displayed below, please click on the forward arrow below to continue with the survey.
[display images for ad #1]
Have you seen this ad on television in the past 30 days?
Yes
No
[if C11=YES, ask C12-C25; IF C11=NO, SKIP TO NEXT AD ]
Rationale: Exposure to ad; Source: NY Media Tracking Survey Online
In the past 30 days, how frequently have you seen this ad on television?
Rarely
Sometimes
Often
Very Often
Rationale: Frequency of exposure to ad; Source: NY Media Tracking Survey Online
Please tell us if you strongly agree, agree, neither agree nor disagree, disagree, or strongly disagree with the following statements.
Strongly Disagree
Disagree
Neither agree nor disagree
Agree
Strongly Agree
[RANDOMIZE ORDER]
C13_1. This ad is worth remembering.
C13_2. This ad grabbed my attention.
C13_3. This ad is powerful.
C13_4. This ad is informative.
C13_5. This ad is meaningful to me.
C13_6. This ad is convincing.
C13_7. This ad is ridiculous.
C13_8. This ad is terrible.
C13_9. This ad was difficult to watch.
Rationale: resonance of ad; Source: FL Online Adult Longitudinal Media Survey
On scale of 1 to 5, where 1 means “not at all” and 5 means “very”, please indicate how much this ad made you feel…
1 2 3 4 5
[RANDOMIZE ORDER] Not at all Very
C14_1. Sad
C14_2. Afraid
C14_3. Irritated
C14_4. Ashamed
C14_5. Discouraged
C14_6. Hopeful
C14_7. Motivated
C14_8. Understood
C14_9. Angry
Rationale: resonance of ad; Source: FL Online Adult Longitudinal Media Survey
On a scale of 1 to 5, where 1 means “not at all” and 5 means “very”, how much did watching this ad make you want to do the following:
[RANDOMIZE ORDER]
Take action to eat healthy foods
1 2 3 4 5
Not at all Very
Rationale: Obesity-prevention-related behaviors; Source: Adapted from Fall 2011 HealthStyles Survey (CDC)
Take action to drink healthy drinks (water, milk, 100% fruit juice)
1 2 3 4 5
Not at all Very
Rationale: Obesity-prevention-related behaviors; Source: Adapted from Fall 2011 HealthStyles Survey (CDC)
Take action to avoid sugar-sweetened soft drinks or fruit drinks (For example, Coke, Sprite, Kool-Aid, Snapple)*
1 2 3 4 5
Not at all Very
Rationale: Obesity-prevention-related behaviors; Source: Adapted from Fall 2011 HealthStyles Survey (CDC)
Take action to be active and do things like walk, bike and play
1 2 3 4 5
Not at all Very
Rationale: Obesity-prevention-related behaviors; Source: Adapted from Fall 2011 HealthStyles Survey (CDC)
[ASK IF S2 >= 1] Take action to get my children to eat healthy foods
1 2 3 4 5
Not at all Very
Rationale: Obesity-prevention-related behaviors; Source: Adapted from Fall 2011 HealthStyles Survey (CDC)
[ASK IF S2 >= 1] Take action to get my children to drink healthy drinks (water, milk, 100% fruit juice)
1 2 3 4 5
Not at all Very
Rationale: Obesity-prevention-related behaviors; Source: Adapted from Fall 2011 HealthStyles Survey (CDC)
[ASK IF S2 >= 1] Take action to keep my children from drinking sugar-sweetened soft drinks or fruit drinks (For example, Coke, Sprite, Kool-Aid, Snapple)*
1 2 3 4 5
Not at all Very
Rationale: Obesity-prevention-related behaviors; Source: Adapted from Fall 2011 HealthStyles Survey (CDC)
[ASK IF S2 >= 1] Take action to get my children to be active and do things like walk, bike and play
1 2 3 4 5
Not at all Very
Rationale: Obesity-prevention-related behaviors; Source: Adapted from Fall 2011 HealthStyles Survey (CDC)
Take action to get more physical education/physical activity for children in schools
1 2 3 4 5
Not at all Very
Rationale: Obesity-prevention-related behaviors; Source: Adapted from Fall 2011 HealthStyles Survey (CDC)
[ASK IF S2 >= 1] Take action to get my children to drink more water throughout the day
1 2 3 4 5
Not at all Very
Rationale: Obesity-prevention-related behaviors; Source: Adapted from Fall 2011 HealthStyles Survey (CDC)
Did you talk to anyone about this ad?
Yes
No
Rationale: resonance of ad; Source: FL Online Adult Longitudinal Media Survey
[REPEAT ABOVE SEQUENCE OF QUESTIONS FOR EACH TV AD SHOWN]
SECTION D: CLOSING QUESTIONS
What is your sex?
Male
Female
Rationale: Demographics; Source: US DHHS Standards. Dorsey and Graham. 2011. New HHS Data Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status. JAMA 306(21):2378-2379.
Are you Hispanic or Latino?
Yes
No
Rationale: Demographics; Source: 2011 BRFSS
Which one or more of the following would you say is your race?
1. White
2. Black or African American
3. American Indian or Alaska Native
4. Asian
5. Native Hawaiian or Other Pacific Islander
Rationale: Demographics; Source: 2011 BRFSS
[ASK IF D4 CONTAINS MORE THAN 1 RESPONSE] Which one of these groups would you say best represents your race?
1. White
2. Black or African American
3. American Indian or Alaska Native
4. Asian
5. Native Hawaiian or Other Pacific Islander
Rationale: Demographics; Source: 2011 BRFSS
What is the highest grade or year of school you completed?
Never attended school or only attended kindergarten
Grades 1 through 8 (Elementary)
Grades 9 through 11 (Some high school)
Grade 12 or GED (High school graduate)
College 1 year to 3 years (Some college or technical school)
College 4 years or more (College graduate)
Rationale: Demographics; Source: 2011 BRFSS
The next question is about the total income of YOUR HOUSEHOLD for the PAST 12 MONTHS. Please include your income PLUS the income of all members living in your household (including cohabiting partners and armed forces members living at home). Please count income BEFORE TAXES and from all sources (such as wages, salaries, tips, net income from a business, interest, dividends, child support, alimony, and Social Security, public assistance, pensions, or retirement benefits).
Thinking about members of your family living in this household, what is your combined annual income, meaning the total pre-tax income from all sources earned in the past year?
$0 to $9,999
$10,000 to $14,999
$15,000 to $19,999
$20,000 to $34,999
$35,000 to $49,999
$50,000 to $74,999
$75,000 to $99,999
$100,000 to $199,999
$200,000 or more
Rationale: Demographics; Source: HINTS
Are you…?
Married
Divorced
Widowed
Separated
Never married
A member of an unmarried couple
Rationale: Demographics; Source: 2011 BRFSS
Which statement best describes your current employment status?.
Employed for wages
Self-employed
Out of work for more than 1 year
Out of work for less than 1 year
A Homemaker
A Student
Retired
Unable to work
Rationale: Demographics; Source: Research Now standard questions for panel members
In what state do you currently reside?
_________Pull Down List of States
Rationale: Demographics; Source: Research Now standard questions for panel members
What county do you live in?
_________Pull Down List of Counties
Rationale: Demographics; Source: Research Now standard questions for panel members
In what zip code do you live?
About how much do you weigh without shoes?
____ pounds
Rationale: Weight for BMI calculation; Source: 2011 BRFSS
About how tall are you without shoes?
____ feet ____ inches
Rationale: Height for BMI calculation; Source: 2011 BRFSS
Has a health care professional ever told you or someone in your household that you are overweight or at risk for being overweight?
1. Yes
2. No
3. Don’t Know
Rationale: Obese or overweight status. Source: Fall 2011 HealthStyles Survey (CDC)
Has a health care professional ever told you or someone in your household that any of your children are overweight or at risk for being overweight?
1. Yes
2. No
3. Don’t Know
Rationale: Child obese or overweight status. Source: Adapted from Fall 2011 HealthStyles Survey (CDC)
Thank you for completing today’s survey. Your input will greatly help researchers assess the impact of television ads about increasing healthy food and drink choices.
You will be awarded $5.00 in e-rewards currency for completing this survey.
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Dooley, Rachel (CDC/ONDIEH/NCCDPHP) (CTR) |
File Modified | 0000-00-00 |
File Created | 2021-01-30 |