3A - NDEP DHS Participant Pretest_110613_OMB30

Form Approved OMB # XXXX-XXXX

Exp. Date XX/XX/2017

Diabetes HealthSense

Participant Pre Survey

The National Diabetes Education Program is trying to find out how well the Diabetes HealthSense website can help people at risk for diabetes and people with diabetes. You will help improve Diabetes HealthSense by taking this survey. This survey will take you about 20 minutes to complete. The survey includes questions about you and your health. Unless the directions say otherwise, please choose one response for each question. Your survey answers are private.

Public reporting burden for this collection of information is estimated to average 20 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-xxxx*). Do not return the completed form to this address.

ID Code

To keep your responses private an ID code will be created using the following information.

Please write down YOUR first and last initials: [Example: Jane Smith is J.S; Jane Doe-Smith is J.D.]

First Initial Last Initial

What is your MONTH and YEAR of BIRTH? [Ex: Write 05/95 if your birthday is May 22, 1995]

/ MM YR

Please choose your program location:

 Site 1  Site 2  Site 3  Site 4  Site 5

 Site 6  Site 7  Site 8  Site 9  Site 10

 Site 12  Site 12  Site 13  Site 14  Site 15

Resources

1. How often do you look for information on preventing or managing diabetes?

 Never  Rarely  Sometimes  Often

2. Where have you received or found information about diabetes prevention and management? (Choose one or more)

 Health care provider

 Mass media (such as TV, radio, newspaper)

 Social media (such as Facebook)

 Internet

 Mail

 Friends/family

 Diabetes education class or program

 Professional associations

 None of the above

3. In the last month, have you participated in a diabetes education class or program? (For example, attended one or more individual or group classes or meetings with a diabetes educator, nurse or dietitian?)

 No

 Yes

3a. If Yes, please specify: ________________________

How would you describe your experience with these NDEP resources?		Never heard of it	Heard of it but do not have it	Have it but have not used it	Have it and used it once	Have it and use it a lot
Small Steps. Big Rewards: Your GAMEPLAN to Prevent Type 2 Diabetes						
4 Steps to Manage Your Diabetes for Life						
Choose More than 50 Ways to Prevent Diabetes						
Paso a Paso						
Tasty Recipes for people with diabetes						

How often in the past month have you used the…	Never	Once this month	2-3 times this month	Once a week	More than once a week
NDEP Diabetes HealthSense Website					
The American Diabetes Association Website (Diabetes.org)					

Risk

6. Has a doctor or other health professional ever told you that you: (Choose one or more)

 Have Type 1 diabetes

 Have Type 2 diabetes

 Have prediabetes or borderline diabetes

 Have high blood glucose (blood sugar), impaired fasting glucose, or impaired glucose tolerance?

 Are at risk for diabetes

7. Which, if any, of the following is true for you? (Choose one or more)

 I have a mother, father, sister, or brother with diabetes

 I have been told by a doctor or other health professional that I have high blood pressure

 I have been told by a doctor or other health professional that I have high cholesterol

 I am NOT physically active

 I was diagnosed with gestational diabetes during any of my pregnancies

 I have given birth to a baby weighing 9 pounds or more

 I smoke

Knowledge and Behaviors

8. Which of the following can quickly raise your blood glucose (blood sugar)?

 Baked chicken

 Swiss cheese

 Baked potato

 Peanut butter

9. Eating foods lower in saturated and trans fat decreases your risk for:

 Nerve disease

 Kidney disease

 Heart disease

 Eye disease

10. The A1C is a measure of your average blood glucose (blood sugar) for the past:

 Day

 Week

 2-3 months

 6 months

11. Which should not be used to treat low blood glucose (blood sugar)?

 3 hard candies

 1/2 cup orange juice

 1 cup diet soft drink

 1 cup skim milk

12. Which of the following is the least amount of physical activity you should do to prevent or manage diabetes?

 30 minutes of activity, five times a week (or 150 minutes per week)

 10 minutes of activity, seven days a week (or 70 minutes per week)

 45 minutes of activity, six days a week (or 270 minutes per week)

13. Which of the following exercise programs includes a mix of strength, flexibility and aerobic activities?

 Walking, running, and swimming

 Lifting weights, push-ups, sit-ups

 Walking, lifting weights, stretching

 Stretching, deep breathing, meditating

14. The best way to lose weight is to:

 Limit amount of physical activity

 Increase portion sizes

 Combine healthy eating and exercise

 Reduce dietary fat without reducing calories

15. Which of the following factors contribute to a person’s weight? (Choose one or more)

 Family history and genetics

 Environment

 Metabolism

 Behavior or habits

16. The best way to take care of your feet is to:

 Check them each day for cuts, blisters and swelling

 Massage them with alcohol each day

 Soak them for one hour each day

 Buy shoes a size larger than usual

17. People with diabetes whose blood glucose (blood sugar) is out of control are at greater risk of which complications? (Choose one or more)

 Serious eye problems

 Circulation problems

 Kidney Problems

 Allergy problems

 Gum disease

 Heart attack or stroke

18. Which of the following may be a sign of an emotional low and/or depression in a person with diabetes?

(Choose one or more)

 Sleeps most of the day

 Does not have an interest or find pleasure in activities

 Does not feel in control of their diabetes

 Discusses diabetes care with family and friends

19. Depression can raise your blood glucose (blood sugar) by causing you to eat too much, do too little, and reduce your motivation to take care of yourself.

 True

 False

20. Which of the following steps are important ways to help you achieve your goals?

(Choose one or more.)

 Making a plan with realistic goals

 Tracking progress

 Avoiding rewards

 Using a support system

For each statement, please check the option that best describes your behaviors.

Have you:	No, and I do not plan to	No, but I plan to within the next 6 months	No, but I plan to within the next month	Yes, I started this less than 6 months ago	Yes, I have been doing this for 6 months or longer
Looked for resources to help you learn about or help you manage your diabetes?					
Set a healthy eating or weight loss goal?					
Reduced the amount of fat in your diet?					
Reduced the number of calories you eat?					
Kept track of what you eat and drink most days of the week?					
Set a physical activity goal?					
Fit exercise into your daily routine (for example, took the stairs instead of elevator, etc)?					
Exercised for 30 minutes at least 5 days a week?					
Kept track of your physical activity most days of the week?					

22. Are you seriously thinking of quitting smoking?

 I have never smoked or I quit more than 6 months ago

 I am not thinking of quitting

 I plan to quit within the next 6 months

 I plan to quit within the next 30 days

 I quit within the last 6 months

Please indicate the degree to which each of the following items may be bothering you.  If you feel that a particular item is not a bother or a problem for you, you would check “1.” If it is very bothersome to you, you might check “6.”

How much do the following feelings bother you in your life?	Not a problem		Moderate Problem		Serious Problem
	1	2	3	4	5	6
Feeling overwhelmed by the demands of living with diabetes or at risk of developing diabetes.	☐	☐	☐	☐	☐	☐
Often feeling that I am failing with my diabetes or diabetes prevention regimen.	☐	☐	☐	☐	☐	☐

How confident do you feel that you can…	Not At All Confident			Totally Confident
	1	2	3	4	5	6
Find resources to help you learn about or manage your diabetes or your risk for diabetes?						
Set a healthy eating or weight loss goal?						
Reduce the amount of fat in your diet?						
Reduce the number of calories you eat?						
Keep track of what you eat and drink most days?						
Set a physical activity goal?						
Fit exercise into your daily routine (for example, take the stairs instead of elevator, etc)?						
Exercise for 30 minutes at least 5 days a week?						
Keep track of your physical activity most days?						

How confident do you feel that you can follow your health care provider’s recommendations for…	Not At All Confident				Totally Confident		Does Not Apply
	1	2	3	4	5	6
Checking your blood glucose (blood sugar).							
Taking medications for diabetes, blood pressure, cholesterol, or heart disease?							
Checking your blood pressure?							
Checking your feet for redness or sores?							

Think back over the past month. How often did you…	Never	Rarely	Sometimes	Often	All of the time
Fill half of your plate with fruits and vegetables at each meal?					
Reduce the amount of fat in your diet?					
Reduce the number of calories you eat?					
Reduce the number of unhealthy snacks and desserts/sweets you eat?					
Reduce your portion sizes?					
Choose drinks without added sugar like diet sodas and unsweetened tea?					
Follow your diet goals and plans?					
Track your diet to measure progress?					

Think back over the past month. How often did you…	Never	Rarely	Sometimes	Often	All of the time
Exercise for 30 minutes at least 5 days a week?					
Fit exercise into your daily routine (for example, take stairs instead of elevator, etc)?					
Do different types of exercises such as stretching, strength training, walking?					
Follow your exercise goals and plans?					
Track your exercise to measure progress?					

Think back over the past month. How often did you do the following to cope with stress and emotions?	Never	Rarely	Sometimes	Often
Exercise?				
Use relaxation techniques such as meditation or deep breathing?				
Participate in a support group?				
Use the support of family and friends?				
Participate in enjoyable hobbies?				
Participate in faith-based activities?				

Think back over the past month. How often did you follow your health care provider’s recommendations for…	Never	Rarely	Sometimes	Often	All of the time	Does not apply
Checking your blood glucose (blood sugar).						
Taking medications for diabetes, blood pressure, cholesterol, or heart disease?						
Checking your blood pressure?						
Checking your feet for redness or sores?						

About You

30. What is your gender?

 Female

 Male

31. How old are you?

 Under 25

 25-34

 35-44

 45-54

 55-64

 65+

32. What is your height? _________ feet and inches

33. What is your weight? ________ lbs

34. Are you Hispanic or Latino?

 No

 Yes

35. What is your race? (Choose one or more)

 Black or African American

 White

 American Indian or Alaska Native

 Native Hawaiian or other Pacific Islander

 Asian

36. Is English your primary language?

 No

 Yes

37. What is the highest level of education you have completed?

 Some high school (grades 9-11)

 High school degree or GED

 Associate degree (2-year)

 College degree (4-year)

 Graduate degree

38. Please check the category that represents your annual household income.

 Less than $15,000

 $15,000-$35,000

 $36,000-$50,000

 $51,000-$75,000

 Over $75,000

39. How often do you use the internet at home?

 Rarely or Never  2-3 times a month  Once a week  2-3 times a week  Daily

40. How often do you need to have someone help you understand written instructions, pamphlets, or other materials from your doctor or pharmacy?

 Never  Rarely  Sometimes  Often  Always