Pst-Intervention Questionnaire

Lawndale Christian Health Center

Patient Centered Care Collaboration

POST QUESTIONNAIRE

Form Approved

OMB No. 0990-

Exp. Date XX/XX/20XX

Post Questionnaire

Health Empowerment Lifestyle Program (HELP)

We would like to ask you some questions about your health, self-care activities, and diabetes knowledge. This information will be used to help us understand your service and informational needs, and to improve our health education program. Your answers are confidential. Do you have any questions before we begin?

Code name of participant: ____________________________________________________

Name of Interviewer (if needed): ________________________________

DEEP program provided in: [ ] Spanish [ ] English

Date of Completion: _________________________

A. The questions that follow ask about your self-care activities during the past 7 days. If you were sick during the past 7 days, think back to the last 7 days that you were not sick. Please circle your answer.
Diet: On how many of the last 7 days did you …
1. Eat five or more servings of fruits and vegetables?	0	1	2	3	4	5	6	7
2. Space carbohydrates (for example, bread, potatoes, pasta, or rice) evenly throughout the day?	0	1	2	3	4	5	6	7
3. Eat high fat foods such as red meat or full-fat dairy products (for example, whole milk, sour cream, cheese or ice cream)?	0	1	2	3	4	5	6	7
Exercise: On how many of the last 7 days did you …
4. Participate in at least 30 minutes of physical activity? [Total minutes of continuous activity, including walking.]	0	1	2	3	4	5	6	7
5. Participate in a specific exercise session (such as swimming, walking, biking) other than what you do around the house or as part of your work?	0	1	2	3	4	5	6	7
Blood Sugar Testing and Foot Care On how many of the last 7 days did you …
6. Test your blood sugar?	0	1	2	3	4	5	6	7
7. Test your blood sugar the number of times recommended by your health care provider?	0	1	2	3	4	5	6	7
8. Check your feet?	0	1	2	3	4	5	6	7
9. Inspect the inside of your shoes?	0	1	2	3	4	5	6	7
Medication: On how many of the last 7 days did you …?
10. Take your recommended diabetes medication?	0	1	2	3	4	5	6	7
11. Take your other recommended medications?	0	1	2	3	4	5	6	7
12. Take at least one aspirin pill?	0	1	2	3	4	5	6	7
Smoking
13. Have you smoked a cigarette-even one puff-during the past 7 days? [ ] Yes [ ] No
14. If yes, how many cigarettes did you smoke on an average day? Number of cigarettes ____

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 (40 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 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer

B. The questions below are about how confident you are in doing certain things to manage your diabetes or other health problems. Check the box in the column that best describes how you feel.	Ratings: 1 = Not at all confident; 2 = Somewhat Confident; 3 = Very Confident;
How confident do you feel that you…	1	2	3
…know how to read and understand food labels?
... can follow your diet when you have to prepare or share food with other people who do not have diabetes?
… can choose the appropriate foods to eat when you are hungry (for example, snacks)?.
… can exercise 15 to 30 minutes, 4 to 5 times a week?
… can do something to prevent your blood sugar level from dropping when you exercise?
… know what to do when your blood sugar level goes higher or lower than it should be?
… can judge when the changes in your illness mean you should visit the doctor?
… can control your diabetes so that it does not interfere with the things you want to do?
… know how to make healthy food choices?

C. The next set of questions test your knowledge of diabetes, and its causes and effects. Circle your answer Y for yes; N for no; DK for don’t know.
1. Eating too much sugar and other sweet foods is a cause of diabetes.	Y N DK
2. The usual cause of diabetes is lack of effective insulin in the body.	Y N DK
3. Diabetes is caused by failure of the kidneys to keep sugar out of the urine.	Y N DK
4. Kidneys produce insulin.	Y N DK
5. In untreated diabetes, the amount of sugar in the blood usually increases.	Y N DK
6. If I am diabetic, my children have a higher chance of being diabetic.	Y N DK
7. Diabetes can be cured.	Y N DK
8. A fasting blood sugar level of 210 is too high.	Y N DK
9. The best way to check my diabetes is by testing my urine.	Y N DK
10. Regular exercise will increase the need for insulin or other diabetic medication.	Y N DK
11. There are two main types of diabetes: type 1 (insulin-dependent) and type 2 (non-insulin dependent)	Y N DK
12. An insulin reaction is caused by too much food.	Y N DK
13. Medication is more important than diet and exercise to control my diabetes.	Y N DK
14. Diabetes often causes poor circulation.	Y N DK
15. Cuts and abrasions on diabetics heal more slowly.	Y N DK
16. Diabetics should take extra care when cutting their toenails.	Y N DK
17. A person with diabetes should cleanse a cut with iodine and alcohol.	Y N DK
18. The way I prepare my food is as important as the food I eat.	Y N DK
19. Diabetes can damage my kidneys.	Y N DK
20. Diabetes can cause loss of feeling in my hands, fingers, and feet.	Y N DK
21. Shaking and sweating are signs of high blood sugar.	Y N DK
22. Frequent urination and thirst are signs of low blood sugar.	Y N DK
23. Tight elastic hose or socks are not bad for diabetics.	Y N DK
24. A diabetic diet consists mostly of special foods.	Y N DK

D. The next set of questions test your knowledge of HIGH BLOOD PRESSURE, and its causes and effects. Circle your answer T for True; F for False; DK for don’t know.
1. High blood pressure and hypertension mean the same thing to the doctor.	T F DK
2. The chances of having high blood pressure increase with age.	T F DK
3. People with high blood pressure should not travel by airplane.	T F DK
4. High blood pressure needn't be treated if it doesn't cause any symptoms.	T F DK
5. To diagnose high blood pressure is necessary to measure it several times.	T F DK
6. High blood pressure may be associated with heart trouble.	T F DK
7. Most people who have high blood pressure and don't know it feel perfectly well.	T F DK
8. The most common cause of high blood pressure is too much salt in the diet.	T F DK
9. One of the main reasons for treating high blood pressure is to prevent a stroke.	T F DK
10. Tiredness is the most common symptom in people who have untreated high blood pressure.	T F DK
11. People who are taking medication for high blood pressure should not stop taking it if they feel well.	T F DK
12. For most people with high blood pressure, the cause is unknown.	T F DK
13. A blood pressure level of 135/85 is considered to be normal.	T F DK
14. People who take fluid pills (diuretics) for high blood pressure are prone to lose potassium in the urine.	T F DK
15. People with high blood pressure usually have fainting spells as a result.	T F DK
16. People with high blood pressure should not take more than one kind of blood pressure pill at a time.	T F DK
17. People with high blood pressure always need to eat a low fat diet.	T F DK
18. A blood pressure of 140/ 110 is considered to be abnormal.	T F DK
19. People with high blood pressure usually have kidney trouble.	T F DK
20. People with high blood pressure can carry on with normal activities.	T F DK
21. Exercise helps to reduce blood pressure.	T F DK
22. Cold and flu medicines may be dangerous for people with high blood pressure.	T F DK
23. Smoking does not affect the blood pressure.	T F DK
24. High blood pressure is hereditary and there is nothing that can be done to reduce the chances of getting it.	T F DK

E. The next set of questions test your knowledge of OVERWEIGHT/OBESITY, and its causes and effects. Circle your answer T for True; F for False; DK for don’t know.
1. Having excess weight does not affect blood pressure.	T F DK
2. Fatty foods are the only reason we gain weight.	T F DK
3. Losing only 10% of the excess weight is sufficient to improve my health.	T F DK
4. Eating in a hurry does not affect my weight.	T F DK
5. The fat accumulated in the abdomen is different than the fat in the rest of the body	T F DK
6. Obesity is hereditary and there is nothing I can do to avoid being becoming obese.	T F DK
7. It is more expensive to be fit than to be overweight/obese.	T F DK
8. TV commercials promoting fried and heavy foods do not affect the way we eat.	T F DK
9. Heart disease is an important consequence of obesity.	T F DK
10. Medications and surgery are the only effective treatments for obesity.	T F DK
11. Fast food is rich in fiber and protein, and low in carbohydrates.	T F DK
12. Exercise for weight loss requires special equipment and going to the gym.	T F DK
13. Obesity is a disease like diabetes or hypertension.	T F DK
14. People older than 65 do not require treatment for obesity.	T F DK
15. The portion sizes at restaurants have decreased for the last 30 years.	T F DK

F. To be completed by staff.

1. A1C Post: ___________________

2. Weight _____________ Height ____ feet ____ inches BMI _______________

3. Blood Pressure ___________________

4. Waist Circumference _____________________

The statements below describe attitudes and beliefs you may have about the health program you participated in and about your health condition(s): diabetes, hypertension, or being overweight. Please rate how much you agree or disagree with each one by placing a check mark in the appropriate box.	1 = I strongly disagree 2 = I somewhat disagree 3 = I’m neutral 4 = I somewhat agree 5= I strongly agree
	1	2	3	4	5
I learned new information that helped me to better manage my health condition
I received useful information from this program
I am putting what I learned from this program into practice
I see positive changes in myself already from being in this program
I am doing something to improve my health condition
It is very important to take care of your health
I’m ready to improve my health
What was important to you about this program?
Information was easy to understand
Materials were easy to use
Materials were written in my language
The classes were taught by a trained professional (community health worker, health educator, pharmacist)
The person who talked with me spoke in my language
The curriculum took my cultural practices into consideration
Someone called me to follow-up on what I learned and remind me of what I should do to manage my health
Group classes
One-on-one sessions at my home

The statements below describe attitudes and beliefs you may have about the best ways for you to learn about your health condition(s): diabetes, hypertension, or being overweight. Please rate how much you agree or disagree with each one by placing a check mark in the appropriate box.	1 = I strongly disagree 2 = I somewhat disagree 3 = I’m neutral 4 = I somewhat agree 5= I strongly agree
	1	2	3	4	5
9. The best way for me to learn about my health condition is from a:
Brochure or pamphlet
Direct mail
Toolkit of materials with a CD
Email
Telephone text message
Facebook posting
Webinar
Group classes
One-on-one sessions at my home
Please rate how satisfied or dissatisfied you are with these statements about this program by placing a check mark in the appropriate box.	1 = Very dissatisfied 2 = Dissatisfied 3= Neutral 4 = Satisfied 5 = Very satisfied
	1	2	3	4	5
How satisfied are you that what you learned helps you to make good decisions about improving your health?
Overall, how satisfied are you with the program?

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