Form 3.1 Survey

ATTACHMENT 9 VISIT 2 QUESTIONNAIRE OMB #: 0925-XXXX

EXPIRATION DATE: XX/XX/XXXX

STUDY ID NUMBER: __________

DATE OF INTERVIEW: __________

INTERVIEWER’S INITIALS: __________

DATE OF DATA ENTRY: __________

Stress and Cortisol Measurement Substudy

Visit 2 Stress Survey

1. Social Support Questionnaire (SSQ) Short-Form (Sherbourne & Stewart, 1991)

I am going to ask you about the various kinds of support, or help from others, that is available to you. For this section, please think about the time since you became pregnant.

	Number	Do Not Know/Refused
How many relatives do you have that you feel close to – people you feel comfortable with, can talk with about personal things, or can ask for help if you need it? Include your husband, parents, children, and other relatives.
How many close friends do you have that you feel close to – people you feel comfortable with, can talk with about personal things, or can ask for help if you need it?

People sometimes look to others for companionship, assistance, or other types of support. Please tell me how often each of the following kinds of support has been available to you if you needed it. Remember to think about how you have felt since you became pregnant. Please turn to Card 2.

	Rarely or None of the Time	A Little of the Time	Some of the Time	Most of the Time	All of the Time	Do Not Know/ Refused
Someone to help you if you were confined to bed.	1	2	3	4	5
Someone you could count on to listen to you when you need to talk.	1	2	3	4	5
Someone to give you good advice about a crisis.	1	2	3	4	5
Someone to take you to the doctor if you needed it.	1	2	3	4	5
Someone who shows you love and affection.	1	2	3	4	5
Someone to have a good time with.	1	2	3	4	5
Someone to give you information to help you understand a situation.	1	2	3	4	5
Someone to confide in or talk to about yourself or your problems.	1	2	3	4	5
Someone to get together with for relaxation.	1	2	3	4	5
Someone to prepare your meals if you were unable to do it yourself.	1	2	3	4	5
Someone whose advice you really want.	1	2	3	4	5
Someone to do things with, to help you get your mind off things.	1	2	3	4	5
Someone to help with daily chores if you were sick.	1	2	3	4	5
Someone to share your most private worries and fears with.	1	2	3	4	5
Someone to turn to for suggestions about how to deal with a personal problem.	1	2	3	4	5
Someone to do something enjoyable with.	1	2	3	4	5
Someone who understands your problems.	1	2	3	4	5
Someone to love and make you feel wanted.	1	2	3	4	5

2. Prenatal Distress Questionnaire (Yali and Lobel, 1999)

To some women, certain aspects of pregnancy are uncomfortable or upsetting, although other women may not be bothered by the same things. Please indicate your own feelings about each statement. Please turn to Card 23.

	Not at All	A Little	Moderately	Very Much	Extremely	Do Not Know/ Refused
I find weight gain during pregnancy troubling.	1	2	3	4	5
Physical symptoms of pregnancy such as nausea, vomiting, swollen feet, or backaches irritate me.	1	2	3	4	5
I am worried about handling the baby when I first come home from the hospital.	1	2	3	4	5
Emotional ups and downs during pregnancy annoy me.	1	2	3	4	5
I am troubled that my relationships with other people important to me are changing due to my pregnancy.	1	2	3	4	5
I am worried about eating healthy food and a balanced diet for the baby.	1	2	3	4	5
Overall, the changes in my body shape and size during pregnancy bother me.	1	2	3	4	5
I am concerned that having a new baby will alter my relationship with the baby's father.	1	2	3	4	5
I worry about having an unhealthy baby.	1	2	3	4	5
I am anxious about labor and delivery.	1	2	3	4	5
The possibility of premature delivery frightens me.	1	2	3	4	5
I am worried that I might not become emotionally attached to the baby.	1	2	3	4	5

3. CES-D Scale (Radloff, 1977)

I am going to read a list of the ways you might feel. For each description that I read to you, please tell me how often you have felt this way during the past 2 weeks—the past 14 days. Please turn to Card 24.

	Rarely or None of the Time	Some or a Little of the Time	Occasionally or a Moderate Amount of the Time	Most or All of the Time	Do Not Know/ Refused
I was bothered by things that usually don’t bother me.	1	2	3	4
I did not feel like eating; my appetite was poor.	1	2	3	4
I felt that I could not shake off the blues even with help from my family or friends.	1	2	3	4
I felt that I was just as good as other people.	1	2	3	4
I had trouble keeping my mind on what I was doing.	1	2	3	4
I felt depressed.	1	2	3	4
I felt that everything I did was an effort.	1	2	3	4
I felt hopeful about the future.	1	2	3	4
I thought my life had been a failure.	1	2	3	4
I felt fearful.	1	2	3	4
My sleep was restless.	1	2	3	4
I was happy.	1	2	3	4
I talked less than usual.	1	2	3	4
I felt lonely.	1	2	3	4
People were unfriendly.	1	2	3	4
I enjoyed life.	1	2	3	4
I had crying spells.	1	2	3	4
I felt sad.	1	2	3	4
I felt that people dislike me.	1	2	3	4
I could not get “going.”	1	2	3	4

4. Perceived Stress Scale (Cohen, 1983)

Now I am going to ask about your feelings or thoughts regarding problems or difficulties that may have occurred during the past month. In each case, you will be asked to indicate how often you felt or thought a certain way. Please turn to Card 25.

During the past month…	Never	Almost Never	Sometimes	Fairly Often	Very Often	Do Not Know/ Refused
How often have you been upset because of something that happened unexpectedly?	1	2	3	4	5
How often have you felt that you were unable to control the important things in your life?	1	2	3	4	5
How often have you felt nervous or “stressed?”	1	2	3	4	5
How often have you felt confident about your ability to handle your personal problems?	1	2	3	4	5
How often have you felt that things were going your way?	1	2	3	4	5
How often have you found that you could not cope with all the things that you had to?	1	2	3	4	5
How often have you been able to control irritations in your life?	1	2	3	4	5
How often have you felt that you were on top of things?	1	2	3	4	5
How often have you been angered because of things that were outside of your control?	1	2	3	4	5
How often have you felt difficulties were piling up so high that you could not overcome them?	1	2	3	4	5

5. Sleep Quality Index (Buysse, 1989)

The following questions relate to your usual sleep habits during the past month only. Your answers should describe your average sleep habits for the days and nights of the past month.

1. When have you usually gone to bed? __________________________

Do not know/Refused

2. How long (in minutes) has it taken you to fall asleep each night? __________________________

Do not know/Refused

3. When have you usually gotten up in the morning? _________________________

Do not know/Refused

4. How many hours of actual sleep did you usually get? (This may be different than the number of hours you spent in bed) _______________________

Do not know/Refused

Please turn to Card 26. During the past month, how often have you had trouble sleeping because you…

	Not During Past Month	Less than Once a Week	Once or Twice a Week	Three or More Times a Week	Do Not Know/ Refused
5. Cannot get to sleep within 30 minutes.	1	2	3	4
6. Wake up in the middle of the night or early morning.	1	2	3	4
Have to get up to use the bathroom.	1	2	3	4
Cannot breathe comfortably.	1	2	3	4
Cough or snore loudly.	1	2	3	4
Feel too cold.	1	2	3	4
Feel too hot.	1	2	3	4
Have bad dreams.	1	2	3	4
Have pain.	1	2	3	4
Other reason(s):	1	2	3	4
During the past month, how often have you taken medicine (prescribed or “over the counter”) to help you sleep?	1	2	3	4
During the past month, how often have you had trouble staying awake while driving, eating meals, or engaging in social activity?	1	2	3	4
During the past month, how much of a problem has it been for you to keep up enough enthusiasm to get things done?	1	2	3	4

Please turn to Card 27.

	Very Good	Fairly Good	Fairly Bad	Very Bad	Do Not Know/ Refused
During the past month, how would you rate your sleep quality overall?	1	2	3	4

6. Life Experiences Survey (Sarason, 1978)

Please turn to Card 38. I am going to list some things that might have occurred to you since you became pregnant. Please answer “yes” for those items you have experienced since you became pregnant, and answer “no” if you have not experienced the item. If you answer “yes,” then please indicate the extent of this impact, either negatively or positively. For example, select -3 if it was an extremely negative or bad impact; select 0 if you thought there was no impact; select +3 to indicate an extremely positive impact.

			Negative/Bad or Positive/Good Impact on your life?							Do Not Know/ Refused
			Negative/Bad­				Positive/Good
	Since you became pregnant, have you….	Did this happen since you became pregnant?	extremely negative	moderately negative	somewhat negative	no impact	somewhat positive	moderately positive	extremely positive
1	Gotten married?	no yes	-3	-2	-1	0	1	2	3
2	Been in jail or a similar institution?	no yes	-3	-2	-1	0	1	2	3
3	Had your husband or partner die?	no yes	-3	-2	-1	0	1	2	3
4	Had a major change in sleeping habits (much more sleep or much less sleep)?	no yes	-3	-2	-1	0	1	2	3
5	Experienced the death of a close family member (your child, father, mother, sister, brother, grandparent or other)?	no yes	-3	-2	-1	0	1	2	3
6	Had a major change in your eating habits (ate much more or less food)?	no yes	-3	-2	-1	0	1	2	3
7	Experienced a foreclosure on a mortgage or a loan?	no yes	-3	-2	-1	0	1	2	3
8	Experienced the death of a close friend?	no yes	-3	-2	-1	0	1	2	3
9	Had an outstanding personal achievement?	no yes	-3	-2	-1	0	1	2	3
10	Had a minor law violation (such as a traffic ticket or disturbing the peace)?	no yes	-3	-2	-1	0	1	2	3
11	Changed your work situation (such as a different work responsibility, a major change in working conditions or working hours)?	no yes	-3	-2	-1	0	1	2	3
12	Started a new job?	no yes	-3	-2	-1	0	1	2	3
13	Had one of your close family members have a serious illness or injury (your husband/partner, child, father, mother, sister, brother, grandparent or other)?	no yes	-3	-2	-1	0	1	2	3
14	Had sexual difficulties?	no yes	-3	-2	-1	0	1	2	3
15	Had trouble with your boss (such as you were in danger of losing your job, being suspended, or demoted)?	no yes	-3	-2	-1	0	1	2	3
16	Had a major change in closeness of family members (increased or decreased closeness)?	no yes	-3	-2	-1	0	1	2	3
17	Gained a new family member (through adoption, or a family member moving in, not including your pregnancy)?	no yes	-3	-2	-1	0	1	2	3
18	Moved to a new place?	no yes	-3	-2	-1	0	1	2	3
19	Had a separation from your husband or partner because you were not getting along?	no yes	-3	-2	-1	0	1	2	3
20	Had a major change in church activities (increased or decreased attendance)?	no yes	-3	-2	-1	0	1	2	3
21	Got back together with your husband or partner after a separation?	no yes	-3	-2	-1	0	1	2	3
22	Had a major change in the number of arguments you have with your husband or partner (a lot more or a lot fewer arguments)?	no yes	-3	-2	-1	0	1	2	3
23	Had a change in your husband’s or partner’s work (he lost his job or started a new job)?	no yes	-3	-2	-1	0	1	2	3
24	Had a major change in usual type and/or amount of recreation?	no yes	-3	-2	-1	0	1	2	3
25	Borrowed more than $15,000 (such as buying a home or business)?	no yes	-3	-2	-1	0	1	2	3
26	Borrowed less than $15,000 (such as buying a car or getting a school loan)?	no yes	-3	-2	-1	0	1	2	3
27	Been fired from a job?	no yes	-3	-2	-1	0	1	2	3
28	Had a major personal illness or injury?	no yes	-3	-2	-1	0	1	2	3
29	Had a major change in social activities, such as parties, movies, visiting, either increased or decreased?	no yes	-3	-2	-1	0	1	2	3
30	Had a major change in living conditions of your family (built a new home, remodeled, had your home or neighborhood decline)?	no yes	-3	-2	-1	0	1	2	3
31	Gotten a divorce?	no yes	-3	-2	-1	0	1	2	3
32	Had a close friend with a serious injury or illness?	no yes	-3	-2	-1	0	1	2	3
33	Had a son or daughter leave home because of a marriage or school?	no yes	-3	-2	-1	0	1	2	3
34	Dropped out or graduated from school?	no yes	-3	-2	-1	0	1	2	3
35	Had a separation from your husband or partner because of work, travel, or family needs?	no yes	-3	-2	-1	0	1	2	3
36	Gotten engaged to be married?	no yes	-3	-2	-1	0	1	2	3
37	Left home for the first time?	no yes	-3	-2	-1	0	1	2	3

7. Williams Discrimination Scale (Williams, 1997)

I am now going to ask you some questions about discrimination that you may or may not experience in your day-to-day life. By discrimination, we mean being treated unfairly because of your race, ethnicity, income level, social class, sex, gender, age, sexual orientation, physical appearance, or religion. In your day-to-day life, please indicate how often any of the following things have happened to you as well as the reason you believe they happened. Please turn to Card 33.

FILL IN THE APPROPRIATE REASON CODE INTO THE REASON CODE COLUMN USING THE TABLE BELOW. IF THE PARTICIPANT SAYS, “OTHER,” ENTER THE CODE AND A SHORT DESCRIPTION.

REASON CODES
1	Ethnicity
2	Gender
3	Race
4	Age
5	Religion
6	Physical Appearance
7	Sexual Orientation
8	Income Level/Social Class
9	Other
88	Do Not Know/Refused

	Never	Less than Once a Year	A Few Times a Year	A Few Times a Month	At Least Once a Week	Almost Everyday	Do Not Know/ Refused	Reason Code
You are treated with less courtesy than other people.	1	2	3	4	5	6
You are treated with less respect than other people.	1	2	3	4	5	6
You receive poorer service than other people at restaurants and stores.	1	2	3	4	5	6
People act as if they think you are not smart.	1	2	3	4	5	6
People act as if they are afraid of you.	1	2	3	4	5	6
People act as if they think you are dishonest.	1	2	3	4	5	6
People act as if they are better than you are.	1	2	3	4	5	6
You are called names or insulted.	1	2	3	4	5	6
You are threatened or harassed.	1	2	3	4	5	6

Please turn to Card 34.

10. For unfair reasons, do you think that you have ever not been hired for a job?

1……No (Skip to Q12)

2……Yes (Continue to Q11)

Do not know/Refused

11. What do you think the main reason was for not hiring you?

Reason Code: __________

IF OTHER: Please specify: _____________________________________________________

12. Have you ever been unfairly stopped, searched, questioned, physically threatened, or abused by the police?

1……No

2……Yes

Do not know/Refused

13. What do you think was the main reason the police treated you that way?

Reason Code: __________

IF OTHER: Please specify: _____________________________________________________

Thank you so much for completing the Visit 2 Stress Survey! Next I will ask you to provide a hair sample like you did during your first visit, but first I would like to ask you a few questions about your hair.

1. Do you use hair products on a regular basis?

1…….Yes

2…….No

Do not know/Refused

2. Do you use a hair dryer, curling iron, or straightener on a regular basis?

1…….Yes

2…….No

Do not know/Refused

3. Is your hair currently dyed, bleached, or highlighted?

1…….Yes

2…….No

Do not know/Refused

4. Do you currently have a perm or has your hair been professionally straightened?

1…….Yes

2…….No

Do not know/Refused

Public reporting burden for this collection of information is estimated to average 45 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0593). Do not return the completed form to this address.