Attachment 6b Health and Media Survey

Health and Media Survey

Form Approved

Health and Media Survey

OMB No. 0920-xxxx
Exp. Date xx/xx/xxxx

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
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?
None
1 Day
2 Days
3 Days
4 Days
5 Days
6 Days
7 Days

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

minutes per day

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.

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During the last 7 days, on how many days did you do moderate physical activities?
None
1 Day
2 Days
3 Days
4 Days
5 Days
6 Days
7 Days

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

minutes per day

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?
None
1 Day
2 Days
3 Days
4 Days
5 Days
6 Days
7 Days

How much time did you usually spend walking on any one of those days?
hours/

minutes per day

Would you say that you usually get enough physical activity?
Yes
No

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What do you usually do when you have a choice about how you spend leisure time?
Almost always choose activities like TV, reading, listening to music, or computers.
Usually choose activities like TV, reading, listening to music, or computers.
Just as likely choose active or inactive activities.
Usually choose activities like walking, bicycling, dancing, or active sports.
Almost always choose activities like walking, bicycling, dancing, or active sports.

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

How many servings of fruits and vegetables do you usually eat each day?
None
1 Serving
2 Servings
3 Servings
4 Servings
5 Servings
6 Servings or more

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

No

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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?
No, and I do NOT intend to in the next 6 months.
No, but I intend to in the next 6 months.
No, but I intend to in the next 30 days.
Yes, I have been, but for LESS than 6 months.
Yes, I have been for MORE than 6 months.

Do you consistently avoid eating high fat foods?
No, and I do NOT intend to in the next 6 months.
No, but I intend to in the next 6 months.
No, but I intend to in the next 30 days.
Yes, I have been, but for LESS than 6 months.
Yes, I have been for MORE than 6 months.

About how often do you drink regular soda or pop that contains sugar? Do not include diet soda or diet
pop.
times per
Never

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.
times per
Never

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?
Zero days
One day
Two days
Three days
Four days
Five days

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Six days
Seven days
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 sugarsweetened 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?
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...

Look for more information on ways to make it easier for you and your family to get healthy foods and drinks
Very unlikely
Somewhat unlikely
Neither likely nor unlikely
Somewhat likely
Very likely

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
Very unlikely
Somewhat unlikely
Neither likely nor unlikely
Somewhat likely
Very likely

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

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Very unlikely
Somewhat unlikely
Neither likely nor unlikely
Somewhat likely
Very likely

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
Very unlikely
Somewhat unlikely
Neither likely nor unlikely
Somewhat likely
Very likely

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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?

Childhood obesity is a problem in my community.
Strongly disagree
Somewhat disagree
Neither agree nor disagree
Somewhat agree
Strongly agree

Adult obesity is a problem in my community.
Strongly disagree
Somewhat disagree
Neither agree nor disagree
Somewhat agree
Strongly agree

Children not getting enough healthy foods and drinks is a problem in my community.
Strongly disagree
Somewhat disagree
Neither agree nor disagree
Somewhat agree
Strongly agree

Children not having access to places to be active and do things like walk, bike, and play is a problem in my
community.
Strongly disagree
Somewhat disagree
Neither agree nor disagree
Somewhat agree
Strongly agree

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

It is important for me to eat healthy foods.
Strongly disagree
Somewhat disagree
Neither agree nor disagree
Somewhat agree
Strongly agree

It is important for me to drink healthy drinks such as water, milk, or 100% fruit juice.
Strongly disagree
Somewhat disagree
Neither agree nor disagree
Somewhat agree
Strongly agree

It is important for me to avoid non-diet sugar-sweetened drinks (For example, Coke, Kool-Aid, Snapple,
Gatorade).
Strongly disagree
Somewhat disagree
Neither agree nor disagree
Somewhat agree
Strongly agree

It is important for me to keep my children from drinking non-diet sugar-sweetened drinks (For example,
Coke, Kool-Aid, Snapple, Gatorade).
Strongly disagree
Somewhat disagree
Neither agree nor disagree
Somewhat agree
Strongly agree

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It is important for me to be active and do things like walk, bike and play.
Strongly disagree
Somewhat disagree
Neither agree nor disagree
Somewhat agree
Strongly agree

It is important for me to get my children to be active and do things like walk, bike and play.
Strongly disagree
Somewhat disagree
Neither agree nor disagree
Somewhat agree
Strongly agree
There are different ideas about what causes people to be overweight. To what extent does each of the following cause
people to be overweight?

Genetics or heredity (something that tends to run in families)
Not at all
A little
Somewhat
A lot

Drinking sugary drinks like soda, not diet drinks or 100% fruit juice
Not at all
A little
Somewhat
A lot

Eating fast food like burgers and fries
Not at all
A little
Somewhat
A lot

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Not getting enough physical activity or exercise
Not at all
A little
Somewhat
A lot

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SECTION C: MEDIA USE AND AWARENESS
On an average day, how much television do you watch?
None
Less than one hour
About 1 hour
About 2 hours
About 3 hours
About 4 hours
5 hours or more

On an average day, how many hours do you listen to the radio?
None
Less than one hour
About 1 hour
About 2 hours
About 3 hours
About 4 hours
5 hours or more

On an average day, how many hours do you use the Internet for personal reasons?
None
Less than one hour
About 1 hour
About 2 hours
About 3 hours
About 4 hours
5 hours or more

What type of Internet connection do you have for your home computer or other primary computer?
Cable/DSL/Broadband/High-Speed
Dial-Up
My computer is not connected to the internet
Not sure

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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

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?
Not at all
Once in the past 30 days
A few times in the past 30 days
Many times in the past 30 days
Daily or almost daily in the past 30 days
Don't know

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

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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.

Were you able to view this video?
Yes
No

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.
Not at all clear and smooth
Somewhat clear and smooth
Clear and smooth
Very clear and smooth
Extremely clear and smooth

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.
Have you seen this ad on television in the past 30 days?
Yes
No

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In the past 30 days, how frequently have you seen this ad on television?
Rarely
Sometimes
Often
Very Often
Please tell us if you strongly agree, agree, neither agree nor disagree, disagree, or strongly disagree with the following
statements.

Strongly Disagree

Disagree

Neither agree
nor disagree

Agree

Strongly Agree

This ad is worth remembering.
This ad grabbed my attention.
This ad is powerful.
This ad is informative.
This ad is meaningful to me.
This ad is convincing.
This ad is ridiculous.
This ad is terrible.
This ad was difficult to watch.
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
Not at all

Sad
Afraid
Irritated

2

3

4

5
Very

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Ashamed
Discouraged
Hopeful
Motivated
Understood
Angry
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:
1
Not at all

Take action to eat healthy foods
Take action to drink healthy drinks
(water, milk, 100% fruit juice)
Take action to avoid sugar-sweetened
soft drinks or fruit drinks (For
example, Coke, Sprite, Kool-Aid,
Snapple)*
Take action to be active and do things
like walk, bike and play
Take action to get my children to eat
healthy foods
Take action to get my children to
drink healthy drinks (water, milk,
100% fruit juice)
Take action to keep my children from
drinking sugar-sweetened soft drinks
or fruit drinks (For example, Coke,
Sprite, Kool-Aid, Snapple)*
Take action to get my children to be
active and do things like walk, bike
and play
Take action to get more physical
education/physical activity for

2

3

4

5
Very

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children in schools
Take action to get my children to
drink more water throughout the day

Did you talk to anyone about this ad?
Yes
No

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SECTION D: CLOSING QUESTIONS
What is your sex?
Male
Female

Are you Hispanic or Latino?
Yes
No

Which one or more of the following would you say is your race?
White
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander

Which one of these groups would you say best represents your race?
White
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander

What is the highest grade or year of school you completed?
Never attended school or only attended kindergarten
Grades 1 through 8 (Elementary)
Grades 9 through 11 (Some high school)
Grade 12 or GED (High school graduate)
College 1 year to 3 years (Some college or technical school)
College 4 years or more (College graduate)

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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).

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?
$0 to $9,999
$10,000 to $14,999
$15,000 to $19,999
$20,000 to $34,999
$35,000 to $49,999
$50,000 to $74,999
$75,000 to $99,999
$100,000 to $199,999
$200,000 or more

Are you...?
Married
Divorced
Widowed
Separated
Never married
A member of an unmarried couple

Which statement best describes your current employment status?
Employed for wages
Self-employed
Out of work for more than 1 year
Out of work for less than 1 year
A Homemaker
A Student
Retired
Unable to work

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In what state do you currently reside?

What county do you live in?

In what zip code do you live?

About how much do you weigh without shoes?
pounds

About how tall are you without shoes?
feet

inches

Has a health care professional ever told you or someone in your household that you are overweight or at
risk for being overweight?
Yes
No
Don't Know

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?
Yes
No
Don't Know