Attachment F-1

National Survey of U.S. Public’s Awareness of Racial and Ethnic Health Disparities

Questionnaire, General Population
Attachment F-1

Form Approved OMB No. 0990-XXXX

Exp. Date XX/XX/XX11

NATIONAL SURVEY OF U.S. PUBLIC’S AWARENESS

OF RACIAL AND ETHNIC HEALTH DISPARITIES

General Population Edition

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990- . The time required to complete this information collection is estimated to average 14 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 537-H, Washington D.C. 20201, Attention: PRA Reports Clearance Officer.

I’d like to begin by asking you some questions about your health care and health information.

1.	At what type of facility do you usually receive your medical care? Is it a doctor’s office, a clinic or health center, an HMO, a hospital emergency room, a hospital outpatient department or some other place? (Select all that apply)

Doctor’s office

Clinic or health center

HMO

Hospital emergency room

Hospital outpatient department

Other (specify: ___________)

(Don’t know)

(Refused)

________________________________________________________________________

2.	How do you typically learn of general medical information? (Select all that

apply)

The Internet

Newspaper

Medical Journals

By talking with my doctor

Television (news/documentary)

Radio

Friends/family

Other (please explain)_______________________________________________

(Don’t’ know)

(Refused)

YES

NO

(DON’T KNOW)

(REFUSED)

________________________________________________________________________

3.	In the last year, have you heard or read anything about racial and ethnic disparities in health and health care in America?

1.	YES (IF YES, BRIEFLY DESCRIBE AND/OR PROVIDE EXAMPLES)

2.	NO

4.	Have you ever heard of any of the following public health campaigns or read any of the following publications?

The US Department of Health and Human Services’ Healthy People 2010

The Agency for Healthcare Research and Quality’s National Healthcare Disparities Report

The Institute of Medicine’s 2003 report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care

The Office of Minority Health’s National Partnership for Action

The PBS Documentary: Unnatural Causes: Is Inequality Making Us Sick?

Yes

No

(Don’t know)

(Refused)

________________________________________________________________________

5.	Thinking about people like yourself, is:

being able to afford the cost of health insurance and necessary medical care;

having enough doctors and other health providers near where they live;

having difficulty getting care because of your race or ethnic background

a major problem, a minor problem or not a problem?

Major problem

Minor problem

Not a problem at all

(Don’t know)

(Refused)

________________________________________________________________________

For the next few questions, I would like you to think about African Americans in our country today.

6.	Do you think the average African American is better off, worse off or just as well off as the average white person in terms of:

a. getting needed health care;

b. infant mortality—that is, a baby’s chance of surviving after birth;

c. life expectancy—that is, how long someone can expect to live?

BETTER OFF

WORSE OFF

JUST AS WELL OFF

(DON’T KNOW)

(REFUSED)

________________________________________________________________________

7.	Do you think the average African American is more likely, just as likely, or less likely to be diagnosed (or to have):

Auto Immune Deficiency Disorder (AIDS) or the HIV virus

Cancer (including cancer of the stomach, prostate, or bladder)

Hypertension

Diabetes

as the average white person?

MORE LIKELY

JUST AS LIKELY

LESS LIKELY

(DON’T KNOW)

(REFUSED)

________________________________________________________________________

8.	When going to a doctor or health clinic for health care services, do you think most

African Americans receive the same quality of health care as whites, higher quality of care or lower quality of health care as most whites?

SAME QUALITY

Higher quality

Lower quality

(Don’t know)

(Refused)

________________________________________________________________________

9.	Do you think the average African American is better off, worse off or just as well off as

the average white person in terms of:

how healthy they are;

getting routine medical care when they need it;

getting specialized treatments or surgery when they need it;

having health insurance?

Better off

Worse off

Just as well off

(Don’t know)

(Refused)

________________________________________________________________________

10.	How big a problem do you think

being able to afford the cost of health insurance and necessary medical care;

having enough doctors and other health providers near where they live;

having difficulty getting care because of their race or ethnic background;

is for the average African American? Is this a major problem, a minor problem or not a problem at all for the average African American?

Major problem

Minor problem

Not a problem at all

(Don’t know)

(Refused)

________________________________________________________________________

Now, thinking about Hispanics or Latinos in our country today.

11.	Do you think the average Hispanic/Latino is better off, worse off or just as well off as the

average white person in terms of:

getting needed health care;

infant mortality—that is, a baby’s chance of surviving after birth;

life expectancy—that is, how long someone can expect to live?

Better off

Worse off

Just as well off

(Don’t know)

(Refused)

________________________________________________________________________

12.	Do you think the average Hispanic/Latino is more likely, just as likely, or less likely to be

diagnosed (or to have):

Auto Immune Deficiency Syndrome (AIDS) or the HIV virus

Cancer (including cancer of the stomach and liver)

Hypertension

Diabetes

as the average white person?

More likely

Just as likely

Less likely

(Don’t know)

(Refused)

________________________________________________________________________

13.	When going to the doctor or health clinic for health care services, do you think most Hispanics/Latinos receive the same quality of health care as whites, higher quality of care or lower quality of health care as most whites?

Same quality

Higher quality

Lower quality

(Don’t know)

(Refused)

________________________________________________________________________

14.	How big a problem do you think:

being able to afford the cost of health insurance and necessary medical care;

having enough doctors and other health providers near where they live;

having difficulty getting care because of their race or ethnic background;

is for the average Hispanic/Latino? Is this a major problem, a minor problem or not a problem at all for the average Hispanic/Latino?

Major problem

Minor problem

Not a problem at all

(Don’t know)

(Refused)

________________________________________________________________________

15.	Do you think the average Hispanic/Latino is better off, worse off or just as well off as the average white person in terms of:

how healthy they are;

getting routine medical care when they need it;

getting specialized treatments or surgery when they need it;

having health insurance?

Better off

Worse off

Just as well off

(Don’t know)

(Refused)

________________________________________________________________________

Now, thinking about Asian Americans/ Pacific Islanders in our country today,

16.	Do you think the average Asian American/Pacific Islander is better off, worse off or just as well off as the average white person in terms of:

getting needed health care;

infant mortality—that is, a baby’s chance of surviving after birth;

life expectancy—that is, how long someone can expect to live?

Better off

Worse off

Just as well off

(Don’t know)

(Refused)

________________________________________________________________________

17.	Do you think the average Asian American/Pacific Islander is more likely, just as likely, or less likely to be diagnosed (or to have):

Auto Immune Deficiency Syndrome (AIDS) or the HIV virus;

Cancer (including cancer of the stomach and liver);

Hypertension;

Diabetes?

as the average white person?

More likely

Just as likely

Less likely

8. (Don’t know)

9. (Refused)

________________________________________________________________________

18.	When going to the doctor or health clinic for health care services, do you think most

Asian American/ Pacific Islanders receive the same quality of health care as whites, higher quality of care or lower quality of health care as most whites?

Same quality

Higher quality

Lower quality

(Don’t know)

(Refused)

_______________________________________________________________________

19.	How big a problem do you think:

being able to afford the cost of health insurance and necessary medical care;

having enough doctors and other health providers near where they live;

having difficulty getting care because of their race or ethnic background is for the average Asian American/ Pacific Islander;

is for the average Asian American/ Pacific Islander? Is this a major problem, a minor problem or not a problem at all for the average Asian American/ Pacific Islander?

Major problem

Minor problem

Not a problem at all

(Don’t know)

(Refused)

________________________________________________________________________

20.	Do you think the average Asian American/ Pacific Islander is better off, worse off or just as well off as the average white person in terms of:

how healthy they are;

getting routine medical care when they need it;

getting specialized treatments or surgery when they need it;

having health insurance?

Better off

Worse off

Just as well off

(Don’t know)

(Refused)

________________________________________________________________________

I have one last set of questions to help us better understand the people who participate in our survey.

21.	Respondent’s gender

Male

Female

________________________________________________________________________

22.	Are you currently married, living as married, widowed, divorced, separated, or have you never been married?

Married

Living as married

Widowed

Divorced

Separated

Never married

(Refused)

________________________________________________________________________

23.	What is your age?

18-98 Record number

99 (Refused)

________________________________________________________________________

24.	What is the last year or grade of school you completed?

Grade 8 or lower

High school incomplete

High school diploma or equivalent

Business, technical or vocational school after high school

Some college, no degree

Two-year or associate’s college degree

Four-year college degree

Graduate or professional school after college

99. (Refused)

________________________________________________________________________

25.	In general, how would you describe your own health? Would you say it is excellent, very good, good, fair or poor?

EXCELLENT

VERY GOOD

GOOD

FAIR

POOR

8.	(DON’T KNOW)

9.	(REFUSED)

26.	Are you yourself of Hispanic, Latino or Spanish origin?

Yes

No

(Don’t know)

(Refused)

________________________________________________________________________

27.	What is your race?

White

Black or African American

Asian American/ Pacific Islander

Other (SPECIFY _________________________)

(Don’t know)

(Refused)

NO INCENTIVE

Thank you very much for participating in this interview. The information you have provided will be useful to policymakers in assessing awareness of health disparities. Do you have anything else to add, or do you have any questions? Again, thank you for your participation.

INCENTIVE

Thank you very much for participating in this interview. The information you have provided will be useful to policymakers in assessing awareness of health disparities. Please tell me your correct address and we will mail you a check for $15 in appreciation of your participation. Do you have anything else to add, or do you have any questions? Again, thank you for your participation.