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Form Approved OMB No.: 0920-1154 Exp. Date: 1/31/2020 |
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FINAL 04/02/2019 |
Your participation in this survey is part of a study about programs that are supposed to make you healthier and is voluntary. You may refuse to take part in the research or exit the survey at any time without penalty. You are agreeing to participate in this study by completing this survey.
CDC estimates the average public reporting burden for this collection of information as 10 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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, GA 30333, ATTN: PRA (0920-1154).
First, we have a few questions to help us determine which questions to ask you.
What is your sex?
Male
Female [Terminate]
Use: Screening
Yes, of Hispanic, Latino, or Spanish origin
No, not of Hispanic, Latino, or Spanish origin
Use: Screening and classification
White
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian or Pacific Islander
Use: Screening and classification
Terminate if respondent selects “No” to #2 and ONLY “White” to #3
What is your age?
Less than 18 years old [Terminate]
18 – 24
25 – 34
35 – 44
45 – 54
55 – 64
65 – 74
75 or older
Use: Screening and classification
Yes
No
I don’t know
Use: Screening and classification
Display if respondent does NOT select “Yes” to #5
Have you ever been told by a doctor or other health professional that you have prediabetes or borderline diabetes?
Yes
No
I don’t know
Use: Screening and classification
Display if respondent does NOT select “Yes” to #5
Have you ever been told by a doctor or other health professional that you had hypertension, also called high blood pressure?
Yes
No
I don’t know
Use: Screening and classification
Display if respondent does NOT select “Yes” to #5
Has your mother, father, brother, or sister been diagnosed with type 2 diabetes?
Yes
No
I don’t know
Use: Screening and classification
Do you usually engage in physical activity for at least 150 minutes (2.5 hours) per week? Physical activity is any activity that speeds up your heart rate and breathing, such as walking at a brisk pace, running, cycling, playing basketball, swimming, etc.
Yes
No
I don’t know
Use: Screening and classification
About how tall are you without shoes?
____ feet {accept integers 4 – 7}
____ inches {accept integers 0 - 11}
Use: Screening and classification
About how much do you weigh without shoes?
____ pounds. {accept integers 75 – 1000)
Use: Screening and classification
Qualified respondents:
Male, AND
Minority Race/Ethnicity, AND
Aged 18+
Disease status
Diagnosed with diabetes, OR
Diagnosed with prediabetes, or
Diagnosed with hypertension, OR
Has a family history (parent or sibling) of type 2 diabetes, OR
Is physically inactive, OR
Aged 45 or older, OR
BMI >23 for Asian, BMI > 25 for all other races
Yes
No
Use: Classification
Now, we’d like to ask a few questions about your current level of physical activity.
Display if respondent indicated that they are physically active regularly in Q9
What helps you to maintain your physical activity routine? (select all that apply)
I have a personal trainer
I work out with a friend, partner, or group
I have people around me that encourage me to exercise regularly
Being able to exercise when it is convenient for me
I pay for classes/sessions ahead of time
I like the way I look and feel afterwards
I pay for a gym membership and I want to get my money’s worth
I don’t have to pay anything to exercise
I’ve just done it so frequently that it has become a habit
I have a health condition that requires me to exercise
My work requires me to be physically active while on the job
I receive benefits through my insurance provider if I exercise
I have fitness or weight loss goals that I am trying to achieve
Other (please specify)
Use: Gather insight into exercise motivations
Display if respondent indicated that they are not physically active in Q9
What factors are keeping you from participating in physical activity for at least 150 minutes (or 2.5 hours) each week? (select all that apply)
I don’t have enough time
I don’t know how to exercise properly
I am not physically able to exercise regularly, due to injury or other limitations
I’m not comfortable in a gym
I don’t have support from my family or friends
I can’t afford it
I don’t have access to a gym/equipment
I don’t like to do it
I don’t feel motivated
I don’t see the benefit of it
The weather (either too cold or too hot)
It isn’t safe for me to exercise outdoors
Other (please specify)
U se: Gather insight into exercise barriers
How comfortable would you feel exercising in a public space? (Exercising includes things like running, walking, stretching, and playing sports)
Very comfortable
Somewhat comfortable
Somewhat uncomfortable
Very uncomfortable
Use: Gather insight into perceptions of potential interventions
Now we have some questions about what types of activities and programs might be interesting to you.
Would you be interested in participating in a group session on healthy living? (Assume the sessions are free and held at a time when you are available)
Yes, definitely
Yes, probably
I’m not sure
No, probably not
No, definitely not
Men with diabetes are three times more likely to have erectile dysfunction (ED). Knowing this, would you be interested in participating in a group session on healthy living that provides information about ways to prevent or delay ED? (Assume the sessions are free and held at a time when you are available)
Yes, definitely
Yes, probably
I’m not sure
No, probably not
No, definitely not
Would you be interested in working with a personal health coach, that is, someone that can help you identify ways to incorporate healthy living in your life? (Assume the health coach is free)
Yes, definitely
Yes, probably
I’m not sure
No, probably not
No, definitely not
Use: Gather insight into perceptions of potential interventions
Display if BMI > 23 for Asian, BMI > 25 for all other races
Would you be interested in participating in a program where you competed in a team to lose weight? (Assume this program is free to participate and at a time when you are available)
Yes, definitely
Yes, probably
I’m not sure
No, probably not
No, definitely not
Use: Gather insight into perceptions of potential interventions
Would you be interested in participating in a program that offered incentives (non-financial or financial) for losing and/or maintaining your weight?
Yes, definitely
Yes, probably
I’m not sure
No, probably not
No, definitely not
Use: Gather insight into perceptions of potential interventions
Would you be interested in participating in a healthy eating program with your family, children, and/or those that live with you?
Yes, definitely
Yes, probably
I’m not sure
No, probably not
No, definitely not
Use: Gather insight into perceptions of potential interventions
Display if respondent selected “yes, definitely” or “yes, probably” to at least two of Q16 - Q21
Below are the programs or activities that you said you might be interested in participating. Drag and drop the items below to rank them in order of interest, #1 being the one that you are most interested in.
[Insert list of programs they selected “yes, definitely” or “yes, probably” in Q16 - Q21]
Use: Gather insight into perceptions of potential interventions; force ranking of level of interest in the various interventions
Display if respondent selects “Yes, definitely” or “Yes, probably” from Q16
How often would you be willing to participate in a group session on healthy living?
Up to once a week
Up to twice a month
Up to once a month
Less than once a month
No preference
Would you be interested in participating in a group session on healthy living that is held online?
Yes, definitely
Yes, probably
I’m not sure
No, probably not
No, definitely not
Display if respondent selects “Yes, definitely” or “Yes, probably” from Q16
Would you prefer to participate in a group session on healthy living that is structured and set up like a class or informal and discussion-based?
Structured and set up like a class
Informal and discussion-based
No preference
Display if respondent selects “Yes, definitely” or “Yes, probably” from Q16
Would you prefer to participate in a group session on healthy living that is held in a classroom or another gathering space such as a community center, barbershop, or coffee shop? (Assume you are able to easily access either option)
Held in a classroom
Held in an existing gathering space (a community center, a barbershop, a coffee shop, etc.)
No preference
Would you be more likely to participate in a group session on healthy living, if the group was led by a man?
Yes, definitely
Yes, probably
I’m not sure
No, probably not
No, definitely not
Would you be more likely to participate in a group session on healthy living, if the group was led by someone from your racial/ethnic group?
Yes, definitely
Yes, probably
I’m not sure
No, probably not
No, definitely not
Display if respondent selects “yes” to Q12
Would you be more likely to participate in a program to improve your health, if the program materials, such as flyers or videos, were provided in the language you speak at home?
Yes, definitely
Yes, probably
I’m not sure
No, probably not
No, definitely not
Would you be more likely to participate in a program to improve your health, if the program materials, such as flyers or videos, used examples and images of people from your racial/ethnic group?
Yes, definitely
Yes, probably
I’m not sure
No, probably not
No, definitely not
Use: Gather insight into importance of creating program materials with particular images
Display if respondent selects “Yes, definitely” or “Yes, probably” from Q16
What is the farthest you would be willing to travel to attend a group session on healthy living? (Assume the program is free and offered at a time you are available)
Not applicable (I would not be willing/able to travel for this at all)
Up to 3 miles
Between 3 and 5 miles
Between 5 and 20 miles
Between 20 and 60 miles
More than 60 miles
Use: Gather insight into willingness to travel to inform intervention requirements
Have you ever participated in any formal programs aimed at improving your health? A formal program could include a group education course, one-on-one sessions with a health coach, a team weight loss competition, or another similar program.
Yes
No
Use: Classification and for skip logic for next question
Display if selected “yes” to #32
Thinking of the formal programs you have previously participated in that have to do with improving your health, what problems or issues did you encounter with these programs? (Select all that apply)
They seemed geared more to women than men
They were too expensive
They were too far away
The people in charge couldn’t relate to me
The hours were inconvenient
The suggestions/solutions did not apply to my lifestyle
The suggestions/solutions did not apply to my culture/background
They felt like a waste of time
I just wasn’t motivated to stick with it
I just didn’t have the time to devote to it
Other (please specify)
None of the above
Use: Gather insight into barriers to participation in interventions in order to inform design
Finally, we have a few more questions for classification purposes only.
Where do you get information about health-related activities? Health-related activities might include things like healthy eating, exercise, illnesses, etc. (select all that apply)
A doctor or doctor’s office
Pharmacy or pharmacist
Church
A friend, family member, or relative
Television
Radio or podcasts
School
A community organization
Your gym or health club
Your barbershop or hair salon
The local government
The internet or social media
Medicine men
Sweat lodges
Somewhere else
None of the above
Use: Gather insight into best places to disseminate information
About how long has it been since you last visited a doctor for a routine checkup?
Within the last 3 months
Between 3 and 6 months ago
Between 6 and 9 months ago
Between 9 and 12 months ago
Between 1 and 2 years ago
Between 2 and 5 years ago
More than 5 years ago
I don’t know
Use: Classification
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)
Use: Classification
Are you currently…?
Employed for wages
Self-employed
Out of work for 1 year or more
Out of work for less than 1 year
A homemaker
A student
Retired
Unable to work
Use: Classification
Never married
Married
Member of an unmarried couple
Widowed
Divorced
Separated
Use: Classification
Display if selected “married” or “member of an unmarried couple” in Q38
Is your spouse or partner supportive of you living a healthy lifestyle?
Yes
No
Use: Classification
Which of the following best describes the location of your primary residence? Is it in a…?
Large city
Small city, suburban area or large town
Village or rural area
A reservation
Use: Classification
Less than $10,000
$10,000 to $14,999
$15,000 to $19,999
$20,000 to $24,999
$25,000 to $34,999
$35,000 to $49,999
$50,000 to $74,999
$75,000 to $99,999
$100,000 to $124,999
$125,000 to $149,999
$150,000 or more
Use: Classification
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Leavitt Partners |
| File Modified | 0000-00-00 |
| File Created | 2021-01-15 |