Follow-up Assessment of Matter of Balance Programs

Attachment 2b

Follow-up Assessment of Matter of Balance Programs

F ollow-up Assessment of Matter of Balance Programs:

Questionnaire for OMB Submission

January 14, 2009

Prepared for the National Center on Injury Prevention and Control by:

Form Approved

OMB Control No. 0920-----

Expiration Date: ----------

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: CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920------).

Interviewer’s Script

Continued from screener script:

E4: Is now a good time for you to talk with me?

If “no,”

Is there a better time that I can schedule with you to complete the survey? Thank you. I’ll call back at that time. STOP

If “yes”,

Great, thank you.

Do you have any questions about the survey before we get started?

First, let me make sure that I have correct information about your Matter of Balance program.

E5: Did you take the Matter of Balance course in Maine starting in the Spring of 2008 and ending on (end date)?

If “no”,

Note correction.

E7: Was your instructor named _________?

If “no”,

Note correction.

E8: What is your current address (include Zip Code)?

Note any corrections.

E9: How many Matter of Balance courses have you taken in the last year since (today-365 days)?

_ _ Number of courses

7 7 Don’t know / Not sure

9 9 Refused

If more than one, proceed with E9. If only one, skip to Section 1.

E10: Why did you decide to take the course more than once?

(Record verbatim response.)

Thank you for this information.

We’ll begin with some questions about your health. You do not have to answer a question. Please tell me if there are any questions you don’t understand.

Section 1: Health Status and Disability

1.1 Has a doctor ever told you that you had

(Hint: Emphasize the word Doctor)

Please read (Check all that apply):

01 Osteoporosis or thinning of the bones?

02 A broken Hip?

03 Stroke?

04 Heart Disease?

05 High Blood Pressure?

06 Arthritis?

07 Long term breathing problems or emphysema?

08 Diabetes or Sugar Diabetes?

09 Parkinson’s Disease?

10 Cancer

11Any other chronic diseases? _________________

77 Don’t know / Not sure

99 Refused

1.2 Think about your health during the past 30 days, from __________ to today. During that time, would you say that in general your physical health was:

Please read:

1 Excellent

2 Very good

3 Good

4 Fair

1.3 During the past 30 days, from __________ to today, how many days would you say your physical health was not good?

_ _ Number of days

8 8 None

7 7 Don’t know / Not sure

9 9 Refused

In the next few questions, “physical health” refers to any illnesses or injuries that you may have had.

1.4 Think about the 30 days before you took Matter of Balance class, from ________to ________. During that time, would you say that in general your physical health was-

Please read:

1 Excellent

2 Very good

3 Good

4 Fair

Or

5 Poor

Do not read:

7 Don’t know / Not sure

9 Refused

1.5 In the 30 days before you took Matter of Balance class, from ________to ________, how many days during that month would you say your physical health was not good?

_ _ Number of days

8 8 None

7 7 Don’t know / Not sure

9 9 Refused

1.6 Do you now have any health problem that requires you to use a walking aid, such as a cane, walker, or wheelchair?

(Include occasional use or use in certain circumstances.)

1 Yes

2 No

7 Don’t know / Not Sure

9 Refused

1.7 In the past 3 months, from __________ to today, how many times have you fallen? By a fall, I mean when a person unintentionally comes to rest on the ground, floor or another lower level.

__(Enter Number.)

If none, skip to Section 1.18

1.8 How many of those falls caused an injury?

__(Enter Number.)

If none, skip to Section 1.18

1.9 In your most recent fall, were you injured?

1-Yes

2-No

7-Unsure

9-Refused

If no, skip to Section 1.18

1.10 For your most recent fall, did you see a doctor or health care provider?

1-Yes

2-No

7-Unsure

9-Refused

1.11 For your most recent fall, were you hospitalized?

1-Yes

2-No

7-Unsure

9-Refused

For this survey, a physical disability is a condition that substantially limits your ability to carry out one or more basic activities, such as walking, climbing stairs, reaching, lifting or carrying.

1.12 Would you say that you currently have a physical disability?

1 Yes

2 No

7 Don’t know / Not Sure

9 Refused

If no, skip to 1.15

1.13 How long have you had this disability?

___ Months

7 Don’t know / Not Sure

9 Refused

1.14 Please describe your physical disability.

(Probe: In other words, what physical limitations do you have; what parts of your body are impaired; is it chronic or temporary?)

Do you live by yourself or do you live with other people?

1 Live alone

2 Live with One

3 Live with more than one person

1.15 Do you need the help of another person with your personal care needs, such as eating, bathing or showering, dressing, getting in or out of bed or a chair, using the toilet, and eating?

1 Yes

2 No

7 Don’t know / Not Sure

9 Refused

1.16 Do you need the help of another person in taking care of your routine needs, such as preparing meals, managing money, shopping for groceries or personal items, performing light or heavy housework, and using a telephone? (NCHS definition)

1 Yes

2 No

7 Don’t know / Not Sure

9 Refused

If no, skip to 1.19

1.17 You said that you need the help of another person for taking care of some of your needs.

Do you get the help you need?

1 Yes

2 No

7 Don’t know / Not Sure

9 Refused

1.18 How many people do you have nearby who will help you during difficult times? For example, to take care of pets, give you a ride to the hospital or store, or help you when you are sick?

Please read:

1 0

2 1

3 2-5

4 6-9

5 10 or more

7 Don’t Know/Not Sure

9 Refused

1.19 In the past 30 days, from ________ to today, how often have you been visited by friends?

__Visits

77 Don’t Know/Not sure

99 Refused

1.20 How many close friends do you have who could give you emotional support during difficult times?

__Friends

77 Don’t Know/Not sure

99 Refused

Section 2: Mental Health and Quality of Life

For the next few questions, “mental health” refers to any stress, depression, or emotional problems.

Please remember that you don’t have to answer a question. Tell me if there are any questions you don’t understand.

Please think about the month before you took Matter of Balance, from ________ to _______.

2.1 In the 30 days before you took Matter of Balance, from __________ to _________, in general, how satisfied were you with your life?

Please read:

1 Very satisfied

2 Satisfied

3 Dissatisfied

4 Very dissatisfied

Do not read:

7 Don't know / Not sure

9 Refused

2.2 In the 30 days before you took Matter of Balance, from __________ to _________, how many days would you say your mental health was not good?

_ _ Number of days

8 8 None [If = 88 (None), go to next section]

7 7 Don’t know / Not sure

9 9 Refused

2.3 In the In the 30 days before you took Matter of Balance, from __________ to _________, how many days did poor physical or mental health keep you from doing your usual activities?

By usual activities I mean such things as taking care of personal needs, preparing meals, managing money, shopping for groceries or personal items, performing light or heavy housework, and using a telephone.

_ _ Number of days

8 8 None

7 7 Don’t know / Not sure

9 9 Refused

Now, please think about past month, from __________to today.

2.4 In the past 30 days, from _________ to today, in general, how satisfied were you with your life?

Please read:

1 Very satisfied

2 Satisfied

3 Dissatisfied

4 Very dissatisfied

Do not read:

7 Don't know / Not sure

9 Refused

2.5 In the past 30 days, from _______ to today, how many days would you say your mental health was not good?

_ _ Number of days

8 8 None [If = 88 (None), go to next section]

7 7 Don’t know / Not sure

9 9 Refused

2.6 In the past 30 days, from _________ to today, how many days did poor physical or mental health keep you from doing your usual activities?

By usual activities I mean such things as taking care of personal needs, preparing meals, managing money, shopping for groceries or personal items, performing light or heavy housework, and using a telephone.

_ _ Number of days

8 8 None

7 7 Don’t know / Not sure

9 9 Refused

2.7 In the past 30 days, how much has your concern about falling interfered with your normal social activities with family, friends, neighbors, or groups?

Please read:

1 Extremely

2 Quite a bit

3 Moderately

4 Slightly

5 Not at all

7 Don't know / Not sure

9 Refused

Section 3: Matter of Balance Effects- Knowledge, Awareness, Self-Efficacy

Now, please think about the month before you took Matter of Balance.

I’m going to list some activities. In the month before you took Matter of Balance, please tell me how sure you were that you could perform each activity without falling, on a scale of 1 to 4. One means you were not at all sure that you could perform the activity without falling, and four means that you were very sure that you could perform the activity without falling. Please remember that you can refuse to answer any question at any time. Also, let me know if there are any questions you do not understand.

3.1-3.12 In the month before you took Matter of Balance, from _________ to ________, how sure were you that you could (insert activity) without falling, from 1, very sure to 4, not at all sure.

(Repeat the question for each new activity in the table below. If the respondent has trouble remembering the scale, repeat the scale definition above.)

Activities:	1 Very sure	2 Somewhat sure	3 Not very sure	4 Not at all sure
1-Clean house
2-Get dressed and undressed
3-Prepare simple meals
4-Take a bath or shower
5-Go shopping
6-Get in and out of a chair
7-Go up and down stairs
8-Walk around the neighborhood
9-Reach into cabinets or closets
10-Hurry to answer the phone
11-Carry bundles from the store
12- Exercise

Again, think about the 30 days before you took Matter of Balance from ________ to _______. How strongly do you agree or disagree with the following statements?

3.13 In the month before the class, I felt I could reduce my risk of falling. (Read responses.)

1- Strongly agree

2- Agree

3- Disagree

4- Strongly disagree

7- Not sure

9- Refused

3.14 In the month before the class, I felt I could overcome my fear of falling. (Read responses.)

1- Strongly agree

2- Agree

3- Disagree

4- Strongly disagree

7- Not sure

9- Refused

3.15 In the month before the class, I felt there were things I could do to keep myself from falling. (Read responses.)

1- Strongly agree

2- Agree

3- Disagree

4- Strongly disagree

7- Not sure

9- Refused

3.16 In the month before the class, I felt falling was something I could control. (Read responses.)

1- Strongly agree

2- Agree

3- Disagree

4- Strongly disagree

7- Not sure

9- Refused

3.17 In the month before the class, how sure were you that you could find a way to get up if you fell? Would you say…(Read responses.)

1- Very sure

2- Sure

3- Somewhat sure

4- Not sure at all sure

7- Don’t know how to answer

9- Refused

3.18 In the month before the class, how sure were you that you could find a way to reduce falls? (Read responses.)

1- Very sure

2- Sure

3- Somewhat sure

4- Not sure at all sure

7- Don’t know how to answer

9- Refused

3.19 In the month before the class, how sure were you that you could protect yourself if you fell. (Read responses.)

1- Very sure

2- Sure

3- Somewhat sure

4- Not sure at all sure

7- Don’t know how to answer

9- Refused

3.20 In the month before the class how sure were you that you could increase your physical strength? (Read responses.)

1- Very sure

2- Sure

3- Somewhat sure

4- Not sure at all sure

7- Don’t know how to answer

9- Refused

3.21 In the month before the class course, how sure were you that you could become more steady on your feet? (Read responses.)

1- Very sure

2- Sure

3- Somewhat sure

4- Not sure at all sure

7- Don’t know how to answer

9- Refused

Now, please think about the past month, from _________to today. I’m going to ask the same questions, but focus on the past month.

3.22-3.33 In the past month, from ________ to today, how sure were you that you could do (insert activity) without falling, from 1, very sure to 4, not at all sure.

(Repeat the question for each new activity in the table below. If the respondent has trouble remembering the scale, repeat the scale definition above.)

Activities:	1 Very sure	2 Somewhat sure	3 Not very sure	4 Not at all sure
22-Clean house
23-Get dressed and undressed
24-Prepare simple meals
25- Take a bath or shower
26-Go shopping
27-Get in and out of a chair
28-Go up and down stairs
29-Walk around the neighborhood
30- Reach into cabinets or closets
31- Hurrying to answer the phone
32-Carry bundles from the store
33- Exercise

Again, think about the past month, from _________to today. How strongly you agree or disagree with the following statements?

3.34 In the past month, I could reduce my risk of falling. (Read responses.)

1- Strongly Agree

2- Agree

3- Disagree

4- Strongly Disagree

7- Not sure

9- Refused

3.35 In the past month, there were things I could do to keep myself from falling. (Read responses.)

1- Strongly Agree

2- Agree

3- Disagree

4- Strongly Disagree

7- Not sure

9- Refused

3.36 In the past month, falling was something I could control. (Read responses.)

1- Strongly Agree

2- Agree

3- Disagree

4- Strongly Disagree

7- Not sure

9- Refused

3.37 In the past month, how sure were you that you could find a way to get up if you fell? Would you say…(Read responses.)

1- Very sure

2- Somewhat sure

3- Not very sure

4- Not at all sure

7- Don’t know how to answer

9- Refused

3.38 In the past month, how sure were you that you could find a way to reduce falls? (Read responses.)

1- Very sure

2- Somewhat sure

3- Not very sure

4- Not at all sure

7- Don’t know how to answer

9- Refused

3.39 In the past month, how sure were you that you could protect yourself if you fell. (Read responses.)

1- Very sure

2- Somewhat sure

3- Not very sure

4- Not at all sure

7- Don’t know how to answer

9- Refused

3.40 In the past month, how sure were you that you could increase your physical strength? (Read responses.)

1- Very sure

2- Somewhat sure

3- Not very sure

4- Not at all sure

7- Don’t know how to answer

9- Refused

3.41 In the past month, how sure were you that you could become more steady on your feet? (Read responses.)

1- Very sure

2- Somewhat sure

3- Not very sure

4- Not at all sure

7- Don’t know how to answer

9- Refused

Now I’m going to ask you some questions about what you may or may not have known before you took Matter of Balance.

3.42 Before I took the class, I knew if the medicines I was taking were increasing my risk of falling. Always, Sometimes, or Never.

1- Always

2- Sometimes

3- Never

7- Don’t know

9- Refused

3.43 Before taking the class, I took my medicine as prescribed. (On the right day, at the right time, and in the right amounts.) Always, sometimes, or never.

1- Always

2- Sometimes

3- Never

7- Don’t know

9- Refused

3.44 Before taking the class, I had my vision checked annually.

1- Always

2- Sometimes

3- Never

7- Don’t know

9- Refused

3.45 Before taking the class, I got new glasses when I needed them.

1- Always

2- Sometimes

3- Never

7- Don’t know

9- Refused

3.46 Before taking the class, if I fell, I would talk about falls with my family.

1- Always

2- Sometimes

3- Never

7- Don’t know

9- Refused

3.47 Before taking the class, if I fell, felt comfortable talking about falls with my doctor.

1- Always

2- Sometimes

3- Never

7- Don’t know

9- Refused

Now, think about the past month, from ________ to today.

3.48 In the past month, I knew if the medicines I was taking were increasing my risk of falling. Always, sometimes, or never.

1- Always

2- Sometimes

3- Never

7- Don’t know

9- Refused

9- Refused

3.49 In the past month, I took my medicine as prescribed. (On the right day, at the right time, and in the right amounts.) Always, sometimes, or never.

1- Always

2- Sometimes

3- Never

7- Don’t know

9- Refused

3.50 In the past month, I had my vision checked.

1- Yes

2- No

3.51 In the past month, I got new glasses if I needed them.

1- Yes

2- No

3.52 In the past month, if I fell, I would talk about falls with my family.

1- Always

2- Sometimes

3- Never

7- Don’t know

9- Refused

3.53 In the past month, if I fell, felt comfortable taking about falls with my doctor.

1- Always

2- Sometimes

3- Never

7- Don’t know

9- Refused

Now I’d like to ask you about changes you may have made since you took Matter of Balance program.

3.54 In the past 6 months, since you took Matter of Balance, how have you changed your home environment to prevent falls?

(Record verbatim response.)

3.55 Please describe how the Matter of Balance program has affected your life.

(Record verbatim response.)

3.56 What would you say was the most important new skill you learned during the Matter of Balance course?

(Record verbatim response.)

3.57 What do you think is the most important thing you do now to prevent falls?

(Record verbatim response)

Section 4: Exercise

Now, think about the month before you took Matter of Balance, from ________ to ________.Please remember that you can refuse to answer any question at any time. Also, let me know if there are any questions you do not understand.

The next questions are about your exercise or physical activity in the month before you took Matter of Balance

4.1 In the 30 days before you took Matter of Balance, what physical activities did you do at least once a week?

By physical activity I mean where you can feel an increase in breathing or heart rate. Examples include: walking briskly, mowing lawn or power motor, scrubbing floors or washing windows.

(Record verbatim response)

Now think about the past month.

4.2 In the last 30 days, what physical activities did you do at least once a week?

(Record verbatim response)

4.3 Which of the following statements best describes how much you walk or exercise now: (Pick only one.)

1-I do not exercise or walk regularly now, and I do not intend to start.

2-I do not exercise or walk regularly, but I have been thinking of starting.

3-I am trying to start to exercise or walk.

4-I have exercised or walked infrequently for over a month.

5-I am doing moderate exercise less than 3 times a week.

6-I have been doing moderate exercise 3 or more times per week.

7- Not sure

9- Refused

Now I’m going to ask you about the activities and exercises you learned during the Matter of Balance course.

4.4 Do you do the exercises using the booklet that you got from your class?

4.5 Are you still doing any of the following activities from Matter of Balance?

(Read each exercise and check all that apply)

Exercise	Check all that apply	Don’t Know
Deep Breathing Warm-up?
Good Morning Stretch?
Shoulder Rolls?
Diagonal Arm Press Across the Body?
Foot Circles?
Seated Knee Raises?
Diagonal Arm Press across the body and Toward the Floor?
Diagonal Arm Press Across the Body and Slightly Overhead?
Rowing Exercise?
Seated Leg Extensions?
Seated Knee Raises, not alternating?
Toe Stands or Heel Raises?
Alternating Steps or Marching in Place?
Side Stepping?
The Box Step (Waltz)?
Standing Hip Extension?
Lift Leg to the Side?
Wrist Rise and Fall?
Finger Spread?
Wrist Rotation?
Touch Elbows Stretch?
Arm Chair Push?
Hip Circles?
Standing Foot Circles?
Heel Cord Stretch?
Ear to Shoulder?
Look Left, Look Right?
Giant Bear Hug?

If “yes” to any of the above exercises, continue to Question 4.6.

4.6 When you do these exercises, do you do them all together and in sequence, as suggested by Matter of Balance?

1-Yes

2-No

7-Unsure

9-Refused

If “yes”, to 4.6, continue to 4.7. If no, skip to 4.9.

4.7 How many days a week do you do the exercises as a sequence?

__ __ (Enter Number of Days)

7 7 Unsure

9 9 Refused

4.8 How long does it take you to complete all of the exercises?

1-Less than half an hour

2-Half an hour

3-More than half an hour, but less than an hour

4-An hour

5-More than an hour

7-Unsure

9-Refused

4.9-4.21 For the exercises you do, how many days a week do you do them? (Read each exercise and the following response categories and record the number corresponding to the selected response.)

Exercise	How Often?	Don’t Know
4.9 Seated Knee Raises?
4.10 Seated Leg Extensions?
4.11 Seated Knee Raises, not alternating?
4.12 Toe Stands or Heel Raises?
4.13 Alternating Steps or Marching in Place?
4.14 Side Stepping?
4.15 The Box Step (Waltz)?
4.16 Standing Hip Extension?
4.17 Lift Leg to the Side?
4.18 Arm Chair Push?
4.19 Hip Circles?
4.20 Standing Foot Circles?
4.21 Heel Cord Stretch?

Section 5: Demographics

In this last section, I’ll ask you some general questions.

5.1 What is your age?

_ _ Code age in years

0 7 Don’t know / Not sure

0 9 Refused

5.2 Are you Hispanic or Latino?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

5.3 Which of the following would you say is your race? You can choose more then one.

(Check all that apply) Please read:

1 White

2 Black or African American

3 Asian

4 Native Hawaiian or Other Pacific Islander

5 American Indian or Alaska Native

Or

6 Other [specify]______________

Do not read:

8 No additional choices

7 Don’t know / Not sure

9 Refused

5.4 Are you…?

Please read:

1 Married

2 Divorced

3 Widowed

4 Separated

5 Never married

Or

6 A member of an unmarried couple

Do not read:

9 Refused

5.5 How many people, other than yourself, live in your household?

___ People

77 Don’t know / Not sure

99 Refused

5.6 What is the highest grade or year of school you completed?

Read only if necessary:

1 Never attended school or only attended kindergarten

2 Grades 1 through 8 (Elementary)

3 Grades 9 through 11 (Some high school)

4 Grade 12 or GED (High school graduate)

5 College 1 year to 3 years (Some college or technical school)

6 College 4 years or more (College graduate)

Do not read:

9 Refused

5.7 What is your annual household income from all sources?

If respondent refuses at ANY income level, code ‘9’ (Refused)

Read:

1 Less than $15,000

2 $15,000-$24,999

3 $25,000-$34,999

4 $35,000-$49,999

5 $50,000-74,999

6 $75,000 or more

Do not read:

77 Don’t know / Not sure

99 Refused

5.8 About how much do you weigh without shoes?

Round fractions up

_ _ _ _ Weight

(pounds/kilograms)

7 7 7 7 Don’t know / Not sure

9 9 9 9 Refused

5.9 About how tall are you without shoes?

Round fractions down

_ _ / _ _ Height

(ft / inches/meters/centimeters)

7 7 7 7 Don’t know / Not sure

9 9 9 9 Refused

This is the end of our survey. Do you have any other comments?

Thank you so much for your time.

If you have questions about this survey, you can contact Hema Desai at 404-589-7066 or Judy Stevens at 770-488-4649.

Thanks again. Goodbye.

Primary References

Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Questionnaire. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, [2006].

Healy, TC., Peng, C., Haynes, MS., McMahon, EM., Botler, JL., Gross, L. (2008) The Feasibility and Effectiveness of Translating Matter of Balance into a Volunteer Lay Leader Model. Journal of Applied Gerontology, volume 27; 34.

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