Questionnaire

Attachment 1: 2016 NHIS Diabetes Primary Prevention Questions to be cognitively tested

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Public reporting burden for this collection of information is estimated to average 60 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-24, Atlanta, GA 30333, ATTN: PRA (0920-0222).

OMB #0920-0222; Expiration Date: 06/30/2015

Doctors and other health professionals often advise patients on ways they can lower their risk for health problems and/or certain diseases.

1. Question ID: APP.001_00.000 Instrument Variable Name: DIBWEIGHT

DURING THE PAST 12 MONTHS, have you tried to lose or control your weight?

01 Yes

02 No

07 Refused

09 Don’t know

2. Question ID: APP.002_00.000 Instrument Variable Name: DIBBEHAV

Are you NOW doing any of the following?

Interviewer Instruction: *Enter all that apply, separate with commas.

01 Increasing your physical activity or exercise

02 Reducing the amount of fat or calories in your diet

03 Participating in a weight loss program

07 Refused

09 Don’t know

3. Question ID: APP.003_00.000 Instrument Variable Name: DIBTEST

About how long has it been since you last had a blood test for high blood sugar or diabetes?

01 Less than 1 year

02 More than 1 year, but not more than 2 years ago

03 More than 2 years, but not more than 3 years ago

04 More than 3 years ago

05 Never

07 Refused

09 Don't know

4. Question ID: APP.004_00.000 Instrument Variable Name: DIBREL

Has your mother, father, brother, or sister EVER been told by a doctor or other health professional that they have diabetes or sugar diabetes?

01 Yes

02 No

07 Refused

09 Don’t know

5. Question ID: ACN.160_00.000 Instrument Variable Name: DIBEV

[Females: Other than during pregnancy, have you EVER been told by a doctor or other health professional that you have diabetes or sugar diabetes?]/[Males: Have you EVER been told by a doctor or other health professional that you have diabetes or sugar diabetes?]

01 Yes (Go to Q7)

02 No (Go to Q6)

03 Borderline (Go to Q9)

07 Refused (Go to Q6)

09 Don't know (Go to Q6)

6. Question ID: ACN.165_00.000 Instrument Variable Name: DIBPRE1

Have you EVER been told by a doctor or other health professional that you have any of the following: prediabetes, impaired fasting glucose, impaired glucose tolerance, borderline diabetes, or high blood sugar?

01 Yes (Go to Q9)

02 No (Male Go to Q16; Female Go to Q14)

07 Refused (Male Go to Q16; Female Go to Q14)

09 Don't know (Male Go to Q16; Female Go to Q14)

7. Question ID: ACN.170_00.000 Instrument Variable Name: DIBAGE

How old were you when a doctor or other health professional FIRST told you that you had diabetes or sugar diabetes?

01-84 1-84 years

85 85+ years

97 Refused

99 Don't know

8. Question ID: APP.005_00.000 Instrument Variable Name: DIBTYPE

What type of diabetes do you have?

01 Type 1

02 Type 2

03 Other

07 Refused

09 Don’t know

9. Question ID: ACN.180_00.000 Instrument Variable Name: INSLN

Are you NOW taking insulin?

01 Yes (Go to Q10)

02 No (Go to Q13)

07 Refused (Go to Q13)

09 Don't know (Go to Q13)

10. Question ID: APP.006_00.000 Instrument Variable Name: DIBINS2

Thinking back to when you were first diagnosed with diabetes, how long was it before you started taking insulin?

01 Less than 1 month

02 1 month to less than 6 months

03 6 months to less than 1 year

04 More than 1 year

07 Refused

09 Don’t know

11. Question ID: APP.007_00.000 Instrument Variable Name: DIBINS3

Since you started taking insulin, have you ever stopped taking it for more than 6 months?

01 Yes (IF Q10=1, 2, or 3, Go to Q12; If Q10=4,R,D, Go to Q 13)

02 No (Go to Q13)

07 Refused (Go to Q13)

09 Don’t know (Go to Q13)

12. Question ID: APP.008_00.000 Instrument Variable Name: DIBINS4

Was this only during the first year after you were diagnosed with diabetes?

01 Yes

02 No

07 Refused

09 Don’t know

13. Question ID: ACN.190_00.000 Instrument Variable Name: DIBPILL

Are you NOW taking diabetic pills to lower your blood sugar? These are sometimes called oral agents or oral hypoglycemic agents.

01 Yes (If Male Go to Q16; If Female Go to Q14)

02 No (If Male Go to Q16; If Female Go to Q14)

07 Refused (If Male Go to Q16; If Female Go to Q14)

09 Don't know (If Male Go to Q16; If Female Go to Q14)

14. Question ID: APP.009_00.000 Instrument Variable Name: DIBGDM

[If Female] During pregnancy, were you ever told by a doctor or other health professional that you had diabetes, sugar diabetes, or gestational diabetes? Please do NOT include diabetes that you may have known about before pregnancy.

01 Yes

02 No

03 Never been pregnant (If Q5=Y, End Interview; If Q5=N, R, D, Go to Q16)

07 Refused

09 Don’t know

15. Question ID: APP.010_00.000 Instrument Variable Name: DIBBABY

[If Female] Have you EVER had a baby that weighed 9 pounds (4 kg) or more at birth?

01 Yes (If Q5=Y, End Interview; If Q5=N, R, D, Go to Intro before Q16)

02 No (If Q5=Y, End Interview; If Q5=N, R, D, Go to Intro before Q16)

07 Refused (If Q5=Y, End Interview; If Q5=N, R, D, Go to Intro before Q16)

09 Don’t Know (If Q5=Y, End Interview; If Q5=N, R, D, Go to Intro before Q16)

These next questions are about a year-long program that can help people prevent type 2 diabetes. This program has 16 weekly sessions during the first 6 months and 6 monthly sessions over the following 6 months. People in the program receive support from a lifestyle coach on achieving and maintaining a healthy lifestyle.

16. Question ID: APP.011_00.000 Instrument Variable Name: DIBPRGM

Have you EVER participated in this type of year-long program to prevent type 2 diabetes?

01 Yes

02 No

07 Refused

09 Don’t know

17. Question ID: APP.012_00.000 Instrument Variable Name: DIBREFER

Has a doctor or other health care professional ever referred you to such a program to prevent type 2 diabetes?

01 Yes (If Q16=Y, End Interview)

02 No

07 Refused

09 Don’t know

 

18. Question ID: APP.013_00.000 Instrument Variable Name: DIBBEGIN

How interested are you in beginning such a year-long program to prevent type 2 diabetes?

Would you say…

Interviewer Instruction: *Read answer categories if necessary.

01 Very interested

02 Somewhat interested

03 Not interested

07 Refused

09 Don't know

19. Question ID: APP.014_00.000 Instrument Variable Name: DIBBARR

Imagine that this type of year-long program to prevent type 2 diabetes is available to you free of charge at a convenient location OR, if you prefer, through your television or the internet. Which of the following reasons is MOST LIKELY to keep you from participating?

Interviewer Instruction: * Read answer choices if necessary.

01 Not worried about diabetes

02 Doctor hasn’t recommended

03 Other programs haven’t helped

04 Transportation issues

05 Child care issues

06 Caring for an elderly or disabled person

07 Other

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