Attachment 6a Health and Media Survey

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/xxxx

Health and Media Survey

Public reporting burden of this collection of information is estimated to average 30 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 NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx)

SECTION A: PHYSICAL ACTIVITY AND NUTRITION

1. Think about all the vigorous activities which take hard physical effort that you did in the last 7 days. Vigorous activities make you breathe harder than normal and may include heavy lifting, aerobics, or fast bicycling. Think only about those physical activities that you did for at least 10 minutes at a time.

During the last 7 days, on how many days did you do vigorous physical activities?

1. None

2. 1 Day

3. 2 Days

4. 3 Days

5. 4 Days

6. 5 Days

7. 6 Days

8. 7 Days

Rationale: Physical activity behavior; Source: International Physical Activity Questionnaire

2. How much time did you usually spend doing vigorous physical activities on any one of those days?

_____hours/minutes per day

Rationale: Physical activity behavior; Source: International Physical Activity Questionnaire

3. Think about the activities which take moderate physical effort that you did in the last 7 days. Moderate physical activity make you breathe somewhat harder than normal and may include carrying light loads, bicycling at a regular pace, or housework. Do not include walking. Again, think about only those physical activities that you did for at least 10 minutes.

During the last 7 days, on how many days did you do moderate physical activities?

1. None

2. 1 Day

3. 2 Days

4. 3 Days

5. 4 Days

6. 5 Days

7. 6 Days

8. 7 Days

Rationale: Physical activity behavior; Source: International Physical Activity Questionnaire

4. How much time did you usually spend doing moderate physical activities on any one of those days?

_____hours/minutes per day

Rationale: Physical activity behavior; Source: International Physical Activity Questionnaire

5. Now think about the time you spent walking in the last 7 days. This includes at work and at home, walking to travel from place to place, and any other walking that you might do solely for recreation, sport, exercise, or leisure.

During the last 7 days, on how many days did you walk for at least 10 minutes at a time?

1. None

2. 1 Day

3. 2 Days

4. 3 Days

5. 4 Days

6. 5 Days

7. 6 Days

8. 7 Days

Rationale: Physical activity behavior; Source: International Physical Activity Questionnaire

6. How much time did you usually spend walking on any one of those days?

_____hours/minutes per day

Rationale: Physical activity behavior; Source: International Physical Activity Questionnaire

7. Would you say that you usually get enough physical activity?

1. Yes

2. No

Rationale: Physical activity behavior; Source: new item

8. What do you usually do when you have a choice about how you spend leisure time?

1. Almost always choose activities like TV, reading, listening to music, or computers.

2. Usually choose activities like TV, reading, listening to music, or computers.

3. Just as likely choose active or inactive activities.

4. Usually choose activities like walking, bicycling, dancing, or active sports.

5. Almost always choose activities like walking, bicycling, dancing, or active sports.

Rationale: Physical activity/sedentary behavior; Source: PACE questionnaire (Beresford et al, 2007)

Fruits and vegetables come in many forms: fresh, frozen, canned, dried, and 100% fruit and vegetable juices. Fruits and vegetables can be cooked or eaten raw. They can also be eaten by themselves or as part of a mixed dish such as soups or casseroles. Use this table to help you count your fruit and vegetable servings...

COUNT AS ONE SERVING:

Vegetables:

1/2 cup of cooked or raw vegetables

1 cup of raw leafy greens

Fruit:

1/2 cup or a medium sized piece of fruit

3/4 cup of 100% fruit juice

1/4 cup of dried fruit

9. How many servings of fruits and vegetables do you usually eat each day?

0. None

1. 1 Serving

2. 2 Servings

3. 3 Servings

4. 4 Servings

5. 5 Servings

6. 6 Servings or more

Rationale: Fruit and vegetable consumption; Source: PACE questionnaire (Beresford et al, 2007)

10. Would you say that you usually get enough servings fruits and vegetables?

1. Yes

2. No

Rationale: fruit and vegetable consumption; Source: new item

11. Do you consistently choose to eat high fiber foods such as high fiber cereals (5 grams/serving), breads (2 grams per serving), beans and legumes, fruits, and vegetables?

1. No, and I do NOT intend to in the next 6 months.

2. No, but I intend to in the next 6 months.

3. No, but I intend to in the next 30 days.

4. Yes, I have been, but for LESS than 6 months.

5. Yes, I have been for MORE than 6 months.

Rationale: Dietary fiber consumption/intentions; Source: PACE questionnaire (Beresford et al, 2007)

12. Do you consistently avoid eating high fat foods?

1. No, and I do NOT intend to in the next 6 months.

2. No, but I intend to in the next 6 months.

3. No, but I intend to in the next 30 days.

4. Yes, I have been, but for LESS than 6 months.

5. Yes, I have been for MORE than 6 months.

Rationale: High fat food avoidance behavior; Source: PACE questionnaire (Beresford et al, 2007)

13. About how often do you drink regular soda or pop that contains sugar? Do not include diet soda or diet pop.

1. _____times per ______day/week/month

2. Never

Rationale: Sugar-sweetened beverage consumption; Source: 2011 BRFSS

14. About how often do you drink sweetened fruit drinks, such as Kool-aid, cranberry, and lemonade? Include fruit drinks you made at home and added sugar to.

1. _____times per ______day/week/month

2. Never

Rationale: Sugar-sweetened beverage consumption; Source: 2011 BRFSS

15. On how many of the past 7 days did you eat food from a fast-food restaurant, such as McDonalds, KFC, Pizza Hut, Taco Bell, or a local fast-food restaurant?

0. Zero days

1. One day

2. Two days

3. Three days

4. Four days

5. Five days

6. Six days

7. Seven days

Rationale: Fast-food consumption; Source: CKG! Healthy Living Awareness Survey

	No, and I don't intend to in the next 6 months	Yes, and I intend to in the next 6 months	Yes, and I intend to in the next 30 days
Do you intend to increase the amount of time you spend doing physical activity?
Do you intend to eat more servings of fruits and vegetables every day?
Do you intend to reduce the amount of sugar-sweetened soft drinks or fruit drinks that you drink (For example, Coke, Sprite, Kool-Aid, Snapple)?
Do you intend to reduce how often you eat food from fast food restaurants?

Rationale: Intentions related to physical activity, nutrition, sugar-sweetened beverage consumption, and fast food consumption; Source: Adapted from PACE questionnaire (Beresford et al, 2007)

Please indicate how likely you are to do each of the following in the next six months. In the next six months how likely are you to…

20. Look for more information on ways to make it easier for you and your family to get healthy foods and drinks

1. Very unlikely

2. Somewhat unlikely

3. Neither likely nor unlikely

4. Somewhat likely

5. Very likely

Rationale: Intentions to seek out information on healthy foods and drink; Source: Fall 2011 HealthStyles Survey (CDC)

21. Look for more information on ways to make it easier for you and your family to be active and do things like walk, bike, and play

1. Very unlikely

2. Somewhat unlikely

3. Neither likely nor unlikely

4. Somewhat likely

5. Very likely

Rationale: Intentions to seek out information on ways to be more physically active; Source: Fall 2011 HealthStyles Survey (CDC)

22. Support policies or other efforts in your community that make it easier for people in your community to get healthy foods and drinks

1. Very unlikely

2. Somewhat unlikely

3. Neither likely nor unlikely

4. Somewhat likely

5. Very likely

Rationale: Intentions to support community-based efforts to increase healthy food and drink access; Source: Adapted from Fall 2011 HealthStyles Survey (CDC)

23. Support policies or other efforts in your community that make it easier for people in your community to be active and do things like walk, bike, and play

1. Very unlikely

2. Somewhat unlikely

3. Neither likely nor unlikely

4. Somewhat likely

5. Very likely

Rationale: Intentions to support community-based efforts to increase access to physical activity resources; Source: Adapted from Fall 2011 HealthStyles Survey (CDC)

SECTION B: ATTITUDES ABOUT HEALTH

The next few questions ask about your community. Different people think about community in different ways. Community can be people in your town, neighborhood, place of worship, or local organization. How much do you agree or disagree with each of the following statements?

1. Childhood obesity is a problem in my community.

1. Strongly disagree

2. Somewhat disagree

3. Neither agree nor disagree

4. Somewhat agree

5. Strongly agree

Rationale: Awareness of childhood obesity; Source: Fall 2011 HealthStyles Survey (CDC)

2. Adult obesity is a problem in my community.

1. Strongly disagree

2. Somewhat disagree

3. Neither agree nor disagree

4. Somewhat agree

5. Strongly agree

Rationale: Awareness of adult obesity; Source: Fall 2011 HealthStyles Survey (CDC)

3. Children not getting enough healthy foods and drinks is a problem in my community.

1. Strongly disagree

2. Somewhat disagree

3. Neither agree nor disagree

4. Somewhat agree

5. Strongly agree

Rationale: Awareness of risk behaviors associated with childhood obesity; Source: Fall 2011 HealthStyles Survey (CDC)

4. Children not having access to places to be active and do things like walk, bike, and play is a problem in my community.

1. Strongly disagree

2. Somewhat disagree

3. Neither agree nor disagree

4. Somewhat agree

5. Strongly agree

Rationale: Awareness of risk behaviors associated with childhood obesity; Source: Fall 2011 HealthStyles Survey (CDC)

How much do you agree or disagree with each of the following statements?

5. It is important for me to eat healthy foods.

1. Strongly disagree

2. Somewhat disagree

3. Neither agree nor disagree

4. Somewhat agree

5. Strongly agree

Rationale: Attitudes about individual healthy eating behavior; Source: New item

6. It is important for me to drink healthy drinks such as water, milk, or 100% fruit juice.

1. Strongly disagree

2. Somewhat disagree

3. Neither agree nor disagree

4. Somewhat agree

5. Strongly agree

Rationale: Attitudes about individual healthy drinking behavior; Source: New item

7. It is important for me to avoid non-diet sugar-sweetened drinks (For example, Coke, Kool-Aid, Snapple, Gatorade).

1. Strongly disagree

2. Somewhat disagree

3. Neither agree nor disagree

4. Somewhat agree

5. Strongly agree

Rationale: Attitudes about individual healthy drinking behavior; Source: New item

8. [ASK IF S2 >= 1] It is important for me to keep my children from drinking non-diet sugar-sweetened drinks (For example, Coke, Kool-Aid, Snapple, Gatorade).

1. Strongly disagree

2. Somewhat disagree

3. Neither agree nor disagree

4. Somewhat agree

5. Strongly agree

Rationale: Attitudes about children’s healthy drinking behavior; Source: New item

9. It is important for me to be active and do things like walk, bike and play.

1. Strongly disagree

2. Somewhat disagree

3. Neither agree nor disagree

4. Somewhat agree

5. Strongly agree

Rationale: Attitudes about physical activity; Source: New item

10. [ASK IF S2 >= 1] It is important for me to get my children to be active and do things like walk, bike and play.

1. Strongly disagree

2. Somewhat disagree

3. Neither agree nor disagree

4. Somewhat agree

5. Strongly agree

Rationale: Attitudes about children’s physical activity; Source: New item

There are different ideas about what causes people to be overweight. To what extent does each of the following cause people to be overweight?

11. Genetics or heredity (something that tends to run in families)

1. Not at all

2. A little

3. Somewhat

4. A lot

Rationale: Beliefs about causes of overweight; Source: Fall 2011 HealthStyles Survey (CDC)

12. Drinking sugary drinks like soda, not diet drinks or 100% fruit juice

1. Not at all

2. A little

3. Somewhat

4. A lot

Rationale: Beliefs about causes of overweight; Source: Fall 2011 HealthStyles Survey (CDC)

13. Eating fast food like burgers and fries

1. Not at all

2. A little

3. Somewhat

4. A lot

Rationale: Beliefs about causes of overweight; Source: Fall 2011 HealthStyles Survey (CDC)

14. Not getting enough physical activity or exercise

1. Not at all

2. A little

3. Somewhat

4. A lot

Rationale: Beliefs about causes of overweight; Source: Fall 2011 HealthStyles Survey (CDC)

SECTION C: MEDIA USE AND AWARENESS

1. On an average day, how much television do you watch?

1. None

2. Less than one hour

3. About 1 hour

4. About 2 hours

5. About 3 hours

6. About 4 hours

7. 5 hours or more

Rationale: use of television; Source: FL Online Adult Longitudinal Media Survey

2. On an average day, how many hours do you listen to the radio?

1. None

2. Less than one hour

3. About 1 hour

4. About 2 hours

5. About 3 hours

6. About 4 hours

7. 5 hours or more

Rationale: use of radio; Source: FL Online Adult Longitudinal Media Survey

3. On an average day, how many hours do you use the Internet for personal reasons?

1. None

2. Less than one hour

3. About 1 hour

4. About 2 hours

5. About 3 hours

6. About 4 hours

7. 5 hours or more

Rationale: use of internet; Source: FL Online Adult Longitudinal Media Survey

4. What type of Internet connection do you have for your home computer or other primary computer?

1. Cable/DSL/Broadband/High-Speed

2. Dial-Up

3. My computer is not connected to the internet

4. Not sure

Rationale: ability to view ads online; Source: NY Media Tracking Survey Online

5. In the past 30 days have you seen, heard, or read any TV, radio, newspaper, or online advertising or messages about any of the following? Please select all that apply.

• Encouraging individuals to eat healthy food

• Encouraging individuals to drink healthy drinks (water, milk, 100% fruit juice)

• Encouraging individuals to get physical activity

• Increasing local healthy food and drink options

• Increasing local physical activity options

• Making it easier in communities to walk, bike, and play

• Getting more physical education and physical activity for children in schools

• Making it easier for children to drink more water throughout the day

• None of these

Rationale: Awareness of NPAO-related media campaigns; Source: Fall 2011 HealthStyles Survey (CDC)

6. In the past 30 days, how often have you seen or heard any advertising or messages that encourage individuals to eat healthy foods, drink healthy beverages, and/or be physically active?

1. Not at all

2. Once in the past 30 days

3. A few times in the past 30 days

4. Many times in the past 30 days

5. Daily or almost daily in the past 30 days

6. Don’t know

Rationale: Frequency of exposure to NPAO-related media campaigns; Source: Adapted from Fall 2011 HealthStyles Survey (CDC)

7. Thinking of the messages that you saw or heard that encouraged individuals to eat healthy foods, drink healthy beverages, and/or be physically active, where did you see or hear them? Please select all that apply.

• Newspapers or magazines

• Billboards or posters

• TV or radio

• Websites

• Online ads

• Facebook

• Twitter

• Promotion at work

• Promotion at a sports or community event

• Somewhere else not listed

• Don’t remember

Rationale: Source of exposure to NPAO-related media campaigns; Source: Fall 2011 HealthStyles Survey (CDC)

Now, we would like you to view a series of television advertisements that have been shown in the U.S. When you are ready, please click on the link below to view the first advertisement. There are a total of XX ads to view. After you view each ad, there will be a few questions that ask about your opinions of the ad.

[randomize order of ads]

[record order]

[SHOW AD #1]

8. Were you able to view this video?

1. Yes

2. No

[if C8=no, skip to C10]

Rationale: exposure to ad; Source: FL Online Adult Longitudinal Media Survey

9. As you viewed this ad, how was it in terms of viewing and sound quality? In answering, think about such issues as whether the images were jerky or unclear or whether the sound was clear and smooth.

1. Not at all clear and smooth

2. Somewhat clear and smooth

3. Clear and smooth

4. Very clear and smooth

5. Extremely clear and smooth

Rationale: clear exposure to ad; Source: NY Media Tracking Survey Online

[ASK C10 ONLY IF C8 = NO]

10. Now we would like to show you some screen shots from a television advertisement that has been shown in the U.S. Once you have viewed the images displayed below, please click on the forward arrow below to continue with the survey.

[display images for ad #1]

11. Have you seen this ad on television in the past 30 days?

1. Yes

2. No

[if C11=YES, ask C12-C25; IF C11=NO, SKIP TO NEXT AD ]

Rationale: Exposure to ad; Source: NY Media Tracking Survey Online

12. In the past 30 days, how frequently have you seen this ad on television?

1. Rarely

2. Sometimes

3. Often

4. Very Often

Rationale: Frequency of exposure to ad; Source: NY Media Tracking Survey Online

13. Please tell us if you strongly agree, agree, neither agree nor disagree, disagree, or strongly disagree with the following statements.

1. Strongly Disagree

2. Disagree

3. Neither agree nor disagree

4. Agree

5. Strongly Agree

[RANDOMIZE ORDER]

C13_1. This ad is worth remembering.

C13_2. This ad grabbed my attention.

C13_3. This ad is powerful.

C13_4. This ad is informative.

C13_5. This ad is meaningful to me.

C13_6. This ad is convincing.

C13_7. This ad is ridiculous.

C13_8. This ad is terrible.

C13_9. This ad was difficult to watch.

Rationale: resonance of ad; Source: FL Online Adult Longitudinal Media Survey

14. On scale of 1 to 5, where 1 means “not at all” and 5 means “very”, please indicate how much this ad made you feel…

1 2 3 4 5

[RANDOMIZE ORDER] Not at all Very

C14_1. Sad

C14_2. Afraid

C14_3. Irritated

C14_4. Ashamed

C14_5. Discouraged

C14_6. Hopeful

C14_7. Motivated

C14_8. Understood

C14_9. Angry

Rationale: resonance of ad; Source: FL Online Adult Longitudinal Media Survey

On a scale of 1 to 5, where 1 means “not at all” and 5 means “very”, how much did watching this ad make you want to do the following:

[RANDOMIZE ORDER]

15. Take action to eat healthy foods

1 2 3 4 5

Not at all Very

Rationale: Obesity-prevention-related behaviors; Source: Adapted from Fall 2011 HealthStyles Survey (CDC)

16. Take action to drink healthy drinks (water, milk, 100% fruit juice)

1 2 3 4 5

Not at all Very

Rationale: Obesity-prevention-related behaviors; Source: Adapted from Fall 2011 HealthStyles Survey (CDC)

17. Take action to avoid sugar-sweetened soft drinks or fruit drinks (For example, Coke, Sprite, Kool-Aid, Snapple)*

1 2 3 4 5

Not at all Very

Rationale: Obesity-prevention-related behaviors; Source: Adapted from Fall 2011 HealthStyles Survey (CDC)

18. Take action to be active and do things like walk, bike and play

1 2 3 4 5

Not at all Very

Rationale: Obesity-prevention-related behaviors; Source: Adapted from Fall 2011 HealthStyles Survey (CDC)

19. [ASK IF S2 >= 1] Take action to get my children to eat healthy foods

1 2 3 4 5

Not at all Very

Rationale: Obesity-prevention-related behaviors; Source: Adapted from Fall 2011 HealthStyles Survey (CDC)

20. [ASK IF S2 >= 1] Take action to get my children to drink healthy drinks (water, milk, 100% fruit juice)

1 2 3 4 5

Not at all Very

Rationale: Obesity-prevention-related behaviors; Source: Adapted from Fall 2011 HealthStyles Survey (CDC)

21. [ASK IF S2 >= 1] Take action to keep my children from drinking sugar-sweetened soft drinks or fruit drinks (For example, Coke, Sprite, Kool-Aid, Snapple)*

1 2 3 4 5

Not at all Very

Rationale: Obesity-prevention-related behaviors; Source: Adapted from Fall 2011 HealthStyles Survey (CDC)

22. [ASK IF S2 >= 1] Take action to get my children to be active and do things like walk, bike and play

1 2 3 4 5

Not at all Very

Rationale: Obesity-prevention-related behaviors; Source: Adapted from Fall 2011 HealthStyles Survey (CDC)

23. Take action to get more physical education/physical activity for children in schools

1 2 3 4 5

Not at all Very

Rationale: Obesity-prevention-related behaviors; Source: Adapted from Fall 2011 HealthStyles Survey (CDC)

24. [ASK IF S2 >= 1] Take action to get my children to drink more water throughout the day

1 2 3 4 5

Not at all Very

Rationale: Obesity-prevention-related behaviors; Source: Adapted from Fall 2011 HealthStyles Survey (CDC)

25. Did you talk to anyone about this ad?

1. Yes

2. No

Rationale: resonance of ad; Source: FL Online Adult Longitudinal Media Survey

[REPEAT ABOVE SEQUENCE OF QUESTIONS FOR EACH TV AD SHOWN]

SECTION D: CLOSING QUESTIONS

1. What is your sex?

1. Male

2. Female

Rationale: Demographics; Source: US DHHS Standards. Dorsey and Graham. 2011. New HHS Data Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status. JAMA 306(21):2378-2379.

2. Are you Hispanic or Latino?

1. Yes

2. No

Rationale: Demographics; Source: 2011 BRFSS

3. Which one or more of the following would you say is your race?

1. White

2. Black or African American

3. American Indian or Alaska Native

4. Asian

5. Native Hawaiian or Other Pacific Islander

Rationale: Demographics; Source: 2011 BRFSS

4. [ASK IF D4 CONTAINS MORE THAN 1 RESPONSE] Which one of these groups would you say best represents your race?

1. White

2. Black or African American

3. American Indian or Alaska Native

4. Asian

5. Native Hawaiian or Other Pacific Islander

Rationale: Demographics; Source: 2011 BRFSS

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

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)

Rationale: Demographics; Source: 2011 BRFSS

The next question is about the total income of YOUR HOUSEHOLD for the PAST 12 MONTHS. Please include your income PLUS the income of all members living in your household (including cohabiting partners and armed forces members living at home). Please count income BEFORE TAXES and from all sources (such as wages, salaries, tips, net income from a business, interest, dividends, child support, alimony, and Social Security, public assistance, pensions, or retirement benefits).

6. Thinking about members of your family living in this household, what is your combined annual income, meaning the total pre-tax income from all sources earned in the past year?

1. $0 to $9,999

2. $10,000 to $14,999

3. $15,000 to $19,999

4. $20,000 to $34,999

5. $35,000 to $49,999

6. $50,000 to $74,999

7. $75,000 to $99,999

8. $100,000 to $199,999

9. $200,000 or more

Rationale: Demographics; Source: HINTS

7. Are you…?

1. Married

2. Divorced

3. Widowed

4. Separated

5. Never married

6. A member of an unmarried couple

Rationale: Demographics; Source: 2011 BRFSS

8. Which statement best describes your current employment status?.

1. Employed for wages

2. Self-employed

3. Out of work for more than 1 year

4. Out of work for less than 1 year

5. A Homemaker

6. A Student

7. Retired

8. Unable to work

Rationale: Demographics; Source: Research Now standard questions for panel members

9. In what state do you currently reside?

_________Pull Down List of States

Rationale: Demographics; Source: Research Now standard questions for panel members

10. What county do you live in?

_________Pull Down List of Counties

Rationale: Demographics; Source: Research Now standard questions for panel members

11. In what zip code do you live?

12. About how much do you weigh without shoes?

____ pounds

Rationale: Weight for BMI calculation; Source: 2011 BRFSS

13. About how tall are you without shoes?

____ feet ____ inches

Rationale: Height for BMI calculation; Source: 2011 BRFSS

14. Has a health care professional ever told you or someone in your household that you are overweight or at risk for being overweight?

1. Yes

2. No

3. Don’t Know

Rationale: Obese or overweight status. Source: Fall 2011 HealthStyles Survey (CDC)

15. Has a health care professional ever told you or someone in your household that any of your children are overweight or at risk for being overweight?

1. Yes

2. No

3. Don’t Know

Rationale: Child obese or overweight status. Source: Adapted from Fall 2011 HealthStyles Survey (CDC)

Thank you for completing today’s survey. Your input will greatly help researchers assess the impact of television ads about increasing healthy food and drink choices.

You will be awarded $5.00 in e-rewards currency for completing this survey.

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