Community Health Wave 4 Survey

Attachment 5b - Wave 4 Healthy Living - Survey - 040413.pdf

CDC and ATSDR Health Message Testing System

Community Health Wave 4 Survey

OMB: 0920-0572

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0920-0572 can be found here:

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Form Approved
OMB No. 0920-0572
Expiration Date: 2/28/2015

Attachment 5b: Online Survey for Wave 4: Healthy
Living
(FHI 360, The Emery Group, & SmithGeiger on behalf of the Centers for Disease Control and
Prevention, Division of Community Health)
April 4, 2013
Introduction
SHOW: About this online survey: Thank you for answering these questions. You are qualified to participate
in this online survey, which is being conducted on behalf of the Centers for Disease Control and
Prevention, sometimes referred to as CDC, in Atlanta. The online survey will take about 22 minutes to
complete. In this online survey you are going to be shown sample advertisements and asked to share your
honest opinions about them.
Your responses will be entered into a database and will only be seen by researchers associated with this
online survey. Your answers will be kept secure to the extent permitted by law. There will be no risk to you.
You may stop at any time. You will receive your gift, as it is explained in your online survey invitation, after
completing the online survey.
If you have any questions about this online survey or about your rights as an online survey participant,
please email them to StudyInfo@fhi360.org.
By clicking 'Next,' I am agreeing to the above project description.
Public Reporting Burden Statement
Public reporting burden of this collection of information is estimated to average 22 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 Information
Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (09200572).

[BACKGROUND HEALTH BEHAVIORS AND ATTITUDES]
[Contemplation and Behavioral Intentions]
Pre-Post Questions
[CHECK S12. IF S12 IS 1 OR MORE, ASK Q1. OTHERS SKIP TO Q1_2]
Q1.

Are you planning to [stop drinking regular soft drinks (non-diet) or other sugary drinks] within the
next 30 days?
1
2

Yes………………………………………………………….. Continue
No……………………………………………………………. Continue
[IF Q1=1 SKIP TO Q1_2. IF Q1=2 CONTINUE TO Q1_1]

Q1_1. Are you planning to [cut back on regular soft drinks (non-diet) or other sugary drinks] within the
next 30 days?
1
2

Yes………………………………………………………….. Continue
No……………………………………………………………. Continue

Q1_2. Are you planning to [be more physically active] within the next 30 days?
1
2

Yes……………………………………………………………. Continue
No……………………………………………………………. Continue

Q1_3. Are you planning to [eat healthier meals and snacks] within the next 30 days?
1
2
Q2.

Are you planning to [do something about your weight] within the next 30 days?
1
2
3
4

Q3.

Yes……………………………………………………………. Continue
No……………………………………………………………. Continue

Yes, I plan to try to lose weight………………………….
Yes, I plan to try to gain weight………………………….
Yes, I plan to try to maintain my current weight……….
No, I have no plans to do anything about my weight….

Continue
Continue
Continue
Continue

During the past 12 months, did you try to cut back on regular soft drinks (non-diet) or other sugary
drinks?
1
2

Yes………………………………………………………….. Continue
No……………………………………………………………. Continue
2

Q3_1. During the past 12 months, did you try to be more physically active?
1
2

Yes………………………………………………………….. Continue
No……………………………………………………………. Continue

Q3_2. During the past 12 months, did you try to eat healthier meals and snacks?
1
2
Q4.

Yes………………………………………………………….. Continue
No……………………………………………………………. Continue

In the past year, have you tried to do any of the following? MULTIPLE RESPONSE
1
2
3

Lose weight…………………………………………………. Continue
Gain weight…………………………………………………. Continue
Maintain your current weight……………………………. Continue

Q4_1. Compared to a year ago, do you weigh…?
1
2
3

Less……………………………………….………….
More………………………………………………….
About the same…………………………………….

Continue
Continue
Continue

Q4_2. And compared to a year ago, would you say that you are…?
1
2
3
Q5.

More healthy………………………………………………. Continue
Less healthy………………………………………………. Continue
About the same ……………………………………………. Continue

Overall, on a scale from 1 to 5, where 1 is not at all interested and 5 is extremely interested, how
interested are you in…?
[CHECK S12. IF S12=1 OR MORE, INSERT A. INSERT B AND C FOR ALL PERSONS]
1
2
3
4
5
A
B
C

Not at all interested………………………………………
A little interested.…………………………………………
Somewhat interested……….……………………………
Very interested……………………………………………
Extremely interested ………………………………….…

Continue
Continue
Continue
Continue
Continue

[Cutting back on regular soft drinks (non-diet) or other sugary drinks]
[Being more physically active]
[Eating healthier meals and snacks]

[THERE IS NO Q6.]
3

Q7.

Thinking about the next six months, how likely are you to…? Please use a scale from 1 to 5, where
1 is not at all likely and 5 is extremely likely. ROTATE A-C AND D-F.
1
2
3
4
5
A
B
C
D
E
F
G

Not at all likely……………………………………………
Somewhat unlikely..……………………………………..
Neither likely nor unlikely..………………………………
Somewhat likely..…………………………………………
Extremely likely ………………………………………….

Continue
Continue
Continue
Continue
Continue

Look for more information on [the health benefits of cutting back on regular soft drinks
(non-diet) or other sugary drinks]
Look for more information on [the health benefits of being more physically active]
Look for more information on [the health benefits of eating more healthy meals and
snacks]
Talk to a friend about_[the health benefits of cutting back on regular soft drinks (non-diet)
or other sugary drinks]
Talk to a friend about_[the health benefits of being more physically active]
Talk to a friend about_[the health benefits of eating more healthy meals and snacks]
Participate in community efforts to reduce obesity

[Self-Efficacy Questions]
Q8.

On a scale from 1 to 5, where 1 indicates that you strongly disagree and 5 indicates that you
strongly agree, please indicate how much you agree or disagree with each of these statements.
1
2
3
4
5

Strongly disagree………………………………………….
Somewhat disagree………………………………………..
Neither agree nor disagree……………………………….
Somewhat agree……………………………………………
Strongly agree………………………………………………

Continue
Continue
Continue
Continue
Continue

A I feel as though I can make a difference regarding [my risk for being overweight or obese]
B I am confident that I can protect myself from [being overweight or obese]
C There are many things I can do to protect myself from [being overweight or obese]
D Generally speaking, it is possible to reduce [one’s risk for being overweight or obese]

[Behavioral Beliefs]
Q9.
On a scale from 1 to 5, where 1 indicates that you strongly disagree and 5 indicates that you
strongly agree, please indicate how much you agree or disagree with each of these statements.
1
2
3
4
5

Continue
Continue
Continue
Continue
Continue

Eliminating regular soft drinks (non-diet) and other sugary drinks during meals every day, would…
A
…make me feel that I was doing something good for my health
B
…make eating meals less enjoyable for me
C
…help me prevent weight gain
D
…make life more stressful for me
E
…help me save money
F
…make it easier for me to drink milk or water at mealtimes
G
…help me lose weight
H
…help me maintain a healthy weight
Q9_1. On a scale from 1 to 5, where 1 indicates that you strongly disagree and 5 indicates that you
strongly agree, please indicate how much you agree or disagree with each of these statements.
1
2
3
4
5

Continue
Continue
Continue
Continue
Continue

Q9_2. On a scale from 1 to 5, where 1 indicates that you strongly disagree and 5 indicates that you
strongly agree, please indicate how much you agree or disagree with each of these statements.
1
2
3
4
5

Continue
Continue
Continue
Continue
Continue

Eating healthier meals and snacks several times per week would…
A
…make me feel that I was doing something good for my health
B
… give me more energy and stamina
C
…help me prevent weight gain
D
…make life more stressful for me
E
…help me save money
F
… make me feel more comfortable with the way I look
G
…help me lose weight
H
…help me maintain a healthy weight
[Community Attitudes]
Q10.

Which of the following statements best describes how you think the problem of obesity should be
solved in your community? SINGLE RESPONSE, RANDOMIZE LIST.

Obesity is an individual problem that is best solved by people taking personal
responsibility for what they eat and how physically active they are………………….Continue

Obesity is a community problem that is best solved by people working together
to make it easier for everyone to eat healthy foods and be physically active……….Continue

Obesity is both an individual and community problem that is best solved by people taking personal
responsibility for what they eat and how physically active they are, and the community working
together to make these behaviors easier to do……………….…………………..
Continue

CAMPAIGN EVALUATIONS
Q11.

[RANDOMLY SELECT TWO CAMPAIGN SEQUENCES TO SHOW]

SHOW: Now we would like to show you a few different health-related ads, including a television, print,
and/or radio ad, and then ask you to evaluate each ad. Even if an ad is from another community or city,
please rate it as if it were an ad from your local community.

Please make sure the volume on your computer is turned up, so that you may both see and/or hear the TV
and radio ads.
Please click “Next” to continue.
NOTE: WHEN THE TV AND RADIO ADS ARE PRESENTED, PLEASE SHOW THE FOLLOWING
MESSAGE ABOVE THE SCREEN: Please be patient while the audio and/or video loads; also note that
the video may stop to buffer from time to time. We do not expect buffering to continue for more than 30
seconds. If you find that it is buffering too long, you can suspend the survey at any time and return to this
point in the survey simply by clicking on the original survey link.
Questions for Each Ad
SHOW: Please answer the following questions about the ad you just viewed.
Q12.

If you saw or heard this message, would it get your attention?
1
2

Yes………………………………………………………….. Continue
No……………………………………………………………. Continue

Q13.

Why or why not? OPEN ENDED…………………………………………….. Continue

Q14.

Is this message believable or not?
1
2

Yes………………………………………………………….. Continue
No……………………………………………………………. Continue

Q15.

Why or why not? OPEN ENDED…………………………………………….. Continue

Q16.

Did you think any of these ads was effective to motivate you or someone else to…?
Please use a scale from 1 to 5, where 1 is not at all effective and 5 is extremely effective.
1
2
3
4
5
A
B
C

Not at all effective…………………………………………
Somewhat ineffective.…………………………………
Neither effective nor ineffective…………………………
Somewhat effective………………………………………
Extremely effective ……………………………………….

Continue
Continue
Continue
Continue
Continue

Cut back on regular soft drinks (non-diet) or other sugary drinks
Be more physically active
Eat healthier meals and snacks

Q17.

Who would you say this ad is trying to reach? Please check all that apply.
1
2
3
4

Q18.

You……………………………………………………..
People like you……………………………………….
Someone else………………………………………..
None of these……………………………… ………..

Continue
Continue
Continue
Continue [EXCLUSIVE
RESPONSE]

On a scale from 1 to 5, where 1 indicates that you strongly disagree, and 5 indicates that you
strongly agree, please indicate how much you agree or disagree with each of the following
statements about this advertisement.
1
2
3
4
5
A
B
C
D
E
F
G
H
I
J

Continue
Continue
Continue
Continue
Continue

Overall, I liked this ad
I am interested in this ad’s topic
I trust the information in this ad
This [ad] was confusing
This [ad] was convincing
This [ad] said something important to me
This [ad] grabbed my attention
I learned something new from this ad
I can do what this ad suggests
This ad was easy to understand
[CHECK Q11. IF A PRINT OR VIDEO AD IS SHOWN, INCLUDE K. IF NOT, OMIT]

I would look at this ad if I saw it

[IF ANSWERED 4-5 TO Q18G ASK Q19. IF 1-3, SKIP TO INSTRUCTIONS BEFORE Q20]
Q19.

What makes it stand out? OPEN ENDED…………………………………. Continue

BEFORE THE NEXT AD IS EVALUATED, UNTIL THE LAST AD, SHOW: Now you will see another ad to
evaluate. Once again, even if an ad is from another community or city, please rate it as if it were an ad from
your local community. Please note that we would like your reaction to each ad individually – we will not ask
you to compare one ad to any other.
[ONLY ASK Q20 ONCE A WHOLE “CAMPAIGN” IS EVALUATED]

Campaign Summary Evaluation
Q20.

Considering the impact of these ads together, please indicate how much you agree or disagree
with each statement.
1
2
3
4
5
A
B
C
D
E
F
G
H
I
J
K

Continue
Continue
Continue
Continue
Continue

I trust the information in this set of ads.
This [set of ads] was convincing.
This [set of ads] grabbed my attention.
This [set of ads] told me something I didn’t already know.
The [message about the health benefits of cutting back on regular soft drinks (non-diet) or
other sugary drinks] was persuasive.
The [message about the health benefits of being more physically active in this set of ads]
was persuasive.
The [message about the health benefits of eating more healthy meals and snacks in this
set of ads] was persuasive
This [set of ads] gave me good reasons to [cut back on regular soft drinks (non-diet) or
other sugary drinks
This [set of ads] gave me good reasons to_[stop drinking regular soft drinks (non-diet) or
other sugary drinks].
This [set of ads] gave me good reasons to_[be more physically active]
This [set of ads] gave me good reasons to_[eat more healthy meals and snacks]

BEFORE THE SECOND CAMPAIGN SEQUENCE IS EVALUATED, SHOW: Now you will see another
series of ads to evaluate. Once again, even if an ad is from another community or city, please rate it as if it
were an ad from your local community.
INDIVIDUAL SPOT EVALUATIONS
Q21. [EACH PERSON WILL SEE 3 OF THE 9 INDIVIDUAL ADS.]
SHOW: We would now like to show you a few more ads and then gather your reactions to them. If you are
watching a television or radio ad, please make sure the volume on your computer is turned up, so that you
may both see and hear the video or audio.
Once again, even if an ad is from another community or city, please rate it as if it were an ad from your
local community. Please note that we would like your reaction to each ad individually – we are not
interested in comparing any of the ads to one another.
Please click “Next” to continue.
9

NOTE: WHEN TELEVISION ADS ARE SHOWN, PLEASE SHOW THE FOLLOWING MESSAGE ABOVE
THE SCREEN: Please be patient while the video or audio loads; please note that the video or audio may
stop to buffer from time to time.”
Questions for Each Ad
SHOW: Please answer the following questions about the ad you just viewed.
Q22.

If you saw or heard this message, would it get your attention?
1
2

Yes……………………………………………………………. Continue
No……………………………………………………………. Continue

Q23.

Why or why not? OPEN ENDED………………………………..……………. Continue

Q24.

Is this message believable or not?
1
2

Yes……………………………………………………………. Continue
No……………………………………………………………... Continue

Q25.

Why or why not? OPEN ENDED………………………………………………. Continue

Q26.

Did you think any of these ads was effective to motivate you or someone else to…?
Please use a scale from 1 to 5, where 1 is not at all effective and 5 is extremely effective.
1
2
3
4
5

Continue
Continue
Continue
Continue
Continue

A [Cutting back on regular soft drinks (non-diet) or other sugary drinks]
B [Being more physically active]
C [Eating healthier meals and snacks]
Q27.

Who would you say this ad is trying to reach? Please check all that apply.
1
2
3
4

Continue
Continue
Continue
Continue [EXCLUSIVE
RESPONSE]

Q28.

Continue
Continue
Continue
Continue
Continue

Overall, I liked this ad
I am interested in this ad’s topic
I trust the information in this ad
This [ad] was confusing
This [ad] was convincing
This [ad] said something important to me
This [ad] grabbed my attention
I learned something new from this ad
I can do what this ad suggests
This ad was easy to understand
I would look at this ad if I saw it
[IF 4-5 TO Q28G ASK Q29. IF 1-3, SKIP TO INSTRUCTIONS AFTER Q29]

Q29.

What makes it stand out? OPEN ENDED……………… Continue

BEFORE THE NEXT AD IS EVALUATED, UNTIL THE LAST AD, SHOW: Now you will see another ad to
evaluate. Once again, even if an ad is from another community or city, please rate it as if it were an ad from
your local community. Please note that we would like your reaction to each ad individually – we are not
interested in comparing any of the ads to one another.
Pre-Post Questions
[Behavioral Intentions]
[CHECK S12. IF S12 IS 1 OR MORE, ASK Q1. OTHERS SKIP TO Q30_2]
Q30.

Are you planning to [stop drinking regular soft drinks (non-diet) or other sugary drinks] within the
next 30 days?
1
2

Yes………………………………………………………….. Continue
No……………………………………………………………. Continue
[IF Q30=1 SKIP TO Q1_2. IF Q30=2 CONTINUE TO Q1_1]

Q30_1. Are you planning to [cut back on regular soft drinks (non-diet) or other sugary drinks] within the
next 30 days?
1
2

Yes………………………………………………………….. Continue
No……………………………………………………………. Continue

Q30_2. Are you planning to [be more physically active] within the next 30 days?
1
2

Yes……………………………………………………………. Continue
No……………………………………………………………. Continue

Q30_3. Are you planning to [eat healthier meals and snacks] within the next 30 days?
1
2

Yes……………………………………………………………. Continue
No……………………………………………………………. Continue

[CHECK S11_1. IF S11_1=1, ASK Q31. OTHERS SKIP TO INSTRUCTIONS BEFORE Q32]
Q31.

Are you planning to [do something about your weight] within the next 30 days?
1
2
3
4

Continue
Continue
Continue
Continue

[CHECK S12. IF S12 IS 1 OR MORE, ASK Q32. OTHERS SKIP TO Q32_1]
Q32.

Overall, on a scale from 1 to 5, where 1 is not at all interested and 5 is extremely interested, how
interested are you in [cutting back on regular soft drinks (non-diet) or other sugary drinks]?
1
2
3
4
5

Continue
Continue
Continue
Continue
Continue

Q32_1 Overall, on a scale from 1 to 5, where 1 is not at all interested and 5 is extremely interested, how
interested are you in [trying to be more physically active]?
1
2
3
4
5

Continue
Continue
Continue
Continue
Continue
12

Q32_2 Overall, on a scale from 1 to 5, where 1 is not at all interested and 5 is extremely interested, how
interested are you in [trying to eat healthier meals and snacks]?
1
2
3
4
5

Continue
Continue
Continue
Continue
Continue

[THERE IS NO Q33]
Q34.

Thinking about the next six months,_how likely are you to…? Please use a scale from 1 to 5,
where 1 is not at all likely and 5 is extremely likely. ROTATE A-C AND D-F.
1
2
3
4
5
A
B
C
D
E
F
G

Not at all likely……………………………………………
Somewhat unlikely..……………………………………
Neither likely nor unlikely..………………………………
Somewhat likely..…………………………………………
Extremely likely ………………………………………….

Continue
Continue
Continue
Continue
Continue

Look for more information on [the health benefits of cutting back on regular soft drinks
(non-diet) or other sugary drinks]
Look for more information on [the health benefits of being more physically active]
Look for more information on [the health benefits of eating more healthy meals and
snacks]
Talk to a friend about [the health benefits of cutting back on regular soft drinks (non-diet) or
other sugary drinks]
Talk to a friend about [the health benefits of being more physically active]
Talk to a friend about [the health benefits of eating more healthy meals and snacks]
Participate in community efforts to reduce obesity

[Self-Efficacy Questions]
Q35.

On a scale from 1 to 5, where 1 indicates that you strongly disagree and 5 indicates that you
strongly agree, please indicate how much you agree or disagree with each of these statements.
1
Strongly disagree…………………………………………. Continue
2
Somewhat disagree……………………………………….. Continue
3
Neither agree nor disagree………………………………. Continue
4
Somewhat agree…………………………………………… Continue
5
Strongly agree……………………………………………… Continue
A
B
C
D

Q36.

I feel as though I can make a difference regarding [my risk for being overweight or obese]
I am confident that I can protect myself from [being overweight or obese]
There are many things I can do to protect myself from [being overweight or obese]
Generally speaking, it is possible to reduce [one’s risk for being overweight or obese]

On a scale from 1 to 5, where 1 indicates that you strongly disagree and 5 indicates that you
strongly agree, please indicate how much you agree or disagree with each of these statements.
1
2
3
4
5

Continue
Continue
Continue
Continue
Continue

Q36_1. On a scale from 1 to 5, where 1 indicates that you strongly disagree and 5 indicates that you
strongly agree, please indicate how much you agree or disagree with each of these statements.
1
2
3
4
5

Continue
Continue
Continue
Continue
Continue

Being more physically active several times per week would…
A
…make me feel that I was doing something good for my health
B
…give me more energy and stamina
C
…help me prevent weight gain
D
…make life more stressful for me
E
…help me save money
F
… make me feel more comfortable with the way I look
G
…help me lose weight
H
…help me maintain a healthy weight
Q36_2. On a scale from 1 to 5, where 1 indicates that you strongly disagree and 5 indicates that you
strongly agree, please indicate how much you agree or disagree with each of these statements.
1
2
3
4
5

Continue
Continue
Continue
Continue
Continue

Eating healthier meals and snacks several times per week would…
A
…make me feel that I was doing something good for my health
B
…give me more energy and stamina
C
…help me prevent weight gain
D
…make life more stressful for me
E
…help me save money
F
… make me feel more comfortable with the way I look
G
…help me lose weight
H
…help me maintain a healthy weight

[Community Attitudes]
Q37.

Which of the following statements best describes how you think the problem of obesity should be
solved in your community? SINGLE RESPONSE, RANDOMIZE LIST.
1 Obesity is an individual problem that is best solved by people taking personal
responsibility for what they eat and how physically active they are………………….Continue
2 Obesity is a community problem that is best solved by people working together
to make it easier for everyone to eat healthy foods and be physically active……….Continue

CLASSIFICATION
SHOW: You’re almost done! These last few questions are for classification purposes only and will be used
for analyzing the results of the survey in total. They will not be identified with you personally.
C1.

Has a healthcare professional ever told you that you are overweight or at risk for being
overweight? SINGLE RESPONSE.
1
2
3

C2.

Yes………………………………………………….
No………………………………………………….
Don’t know / not sure …………………………….

Continue
Continue
Continue

Has anyone else in your household been identified by a health care professional as being
overweight or at risk for being overweight? SINGLE RESPONSE.
1
2
3

Yes………………………………………………….
No………………………………………………….
Don’t know / not sure ………………………….

Continue
Continue
Continue

C3.

What is your current occupational status? Would you say…? Please select the option that best
applies to you. SINGLE RESPONSE
1
2
3
4
5
6
7
8
9
10

C4.

Married …………………………………………………
Unmarried living with a partner………………………
Divorced …………………………………………………
Widowed …………………………………………………
Separated…………………………………………………
Single, never been married ……………………………
Don’t Know/Not Sure …………………………………..
Refused………………..…………………………….……

Continue
Continue
Continue
Continue
Continue
Continue
Continue
Continue

How many children (under age 18) live in your household?
1

C6.

Continue
Continue
Continue
Continue
Continue
Continue
Continue
Continue
Continue
Continue

What is your marital status?
1
2
3
4
5
6
7
8

C5.

Employed full time………………………………………….
Employed part time……………………………………….
Unemployed……………………………………………….
Homemaker……………………………………………….
Student ………………………………………………..….
Retired ………………………………………………..….
Disabled ………………………………………………..….
Other (Please specify: _________)………………..….
Don’t Know/Not Sure ………………..………………….
Refused………………..………………………………….

Enter number: [Numeric Response] ………………………………………
Continue

What is your household’s total income from all sources before taxes? SINGLE RESPONSE, DO
NOT ROTATE
1
2
3
4
5
6
7
8
9

Under $20,000……..…………………………….…………….
$20,000 to $29,999 .…………………………….…………….
$30,000 to $39,999 .…………………………….…………….
$40,000 to $49,999 .…………………………….…………….
$50,000 to $74,999 .…………………………….…………….
$75,000 to $99,999 .…………………………….…………….
$100,000 to $199,999 .…………………………….…………
Over $200,000 .……………………..………….…………….
Prefer not to say.…………………………….……………….

Continue
Continue
Continue
Continue
Continue
Continue
Continue
Continue
Continue

C7.

In the following list of items, please indicate which devices you currently use or own. MULTIPLE
RESPONSE
1
2
3
4
5

A desktop computer…………………………………………………………………
A laptop computer………………………………………………………………..…
A smartphone, such as an iPhone, BlackBerry, HTC EVO, Droid, etc. ……
A tablet, such as an iPad, Kindle Fire, Nook Color, Motorola Xoom, etc…..
An iPod or other mp3 player ………………………………………………………

Continue
Continue
Continue
Continue
Continue

SHOW: That is the last question. Thank you for your time. Please click “OK” to confirm your
participation.

File Type	application/pdf
Author	lplanas
File Modified	2013-04-04
File Created	2013-04-04