Community Survey

Form Approved

OMB No. 0990-

Exp. Date XX/XX/20XX

SURVEY INSTRUMENT

Assessment of the Behavioral Health of Women in Western North Dakota and Eastern Montana

Note: the survey instrument is designed for electronic administration via email, but it can also be converted to paper format. The survey can be self-administered or with the assistance of an interviewer/administrator in person.

WELCOME AND INFORMED CONSENT

Thank you for taking this confidential survey to evaluate women’s physical and behavioral health in your community. Before we begin, we ask that you read our informed consent form.

Background

The 2006 discovery and subsequent development of the Parshall Oil Field has led to significant economic opportunities and population growth in in western North Dakota and eastern Montana. Rapid population growth has many intended and unintended consequences, both positive and negative, on the social and economic environment of the region and the population’s health and well-being.

Purpose

The purpose of this survey is to understand the perceptions and experiences of health and behavioral health of women in western North Dakota and eastern Montana. Behavioral health is a term that covers the full range of mental and emotional well-being – from the basics of how we cope with day-to-day challenges of life, to the treatment of mental illnesses, such as depression or personality disorder, as well as substance use disorders and other addictive behaviors.

Our study includes interviews with key stakeholders, focus groups and surveys with community members. Throughout the project, our assessment is emphasizing community engagement. Our work is guided by community organizations, tribes, and state partners to ensure the assessment produces evidence that will benefit women living in “boomtown” and surrounding communities.

What Happens In This Research Study

If you are a woman residing in North Dakota or Montana, you are eligible to take this survey. The survey will ask you questions about your health, about changes happening in your community related to the energy industry, and what you think about the role of energy development on women’s behavioral health. This survey contains 51 questions and will take 10 minutes. There are no “right” or “wrong” answers. Once you complete the survey, your participation in the study will be completed. There will be no further invitations, activities or contact with study personnel.

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-XXXX. The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete 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

Confidentiality

Your responses will be kept private to the extent allowed by law. Information from this survey will be used for community improvement and may be published; however, your name will not be used in any publications. Responses will be summarized in a report across all survey participants.

If you accept these terms and wish to take the survey, please click the button below:

[“I Accept/Understand” button]

Survey Questionnaire

DEMOGRAPHICS

1. What is your age? [BRFSS 2017]

• __________ (code age in years)

2. Are you Hispanic or Latina/o? [BRFSS 2017]

• Yes

• No

3. What is your race? (check all that apply) [US Census/BRFSS 2017]

• White

• Black or African American

• Alaska Native or American Indian

• Asian

• Pacific Islander

4. Do you currently live on an American Indian reservation?

   • Yes

   • No

5. What is your zip code? _____________

6. Where were you born?

• United States

  • Please specify state: __________

• Outside the United States

  • Please specify country: __________

7. What is the highest grade or level of school you have finished? [BRFSS 2017/US Census]

• I didn’t go to school

• 8th grade or less

• Some high school but did not graduate

• High School graduate or GED

• Some college / vocational or technical school

• Graduated from college, graduate school

8. How would you describe your relationship status?

• Married

• Divorced

• Widowed

• Separated

• Never married

• Member of an unmarried couple

9. Do you have any children?

• Yes, residing with me

• Yes, not residing with me

• No

10. What language do you speak most at home? (select one option)

• English

• Spanish

• Other, please specify: __________

11. What best describes your employment status? Please select one. [BRFSS 2017]

• Employed for wages

• Self-employed

• Out of work for 1 year or more

• Out of work for less than 1 year

• A Homemaker

• A Student

• Retired

• I am unable to work

12. What is your annual household income? [Adapted from BRFSS 2017]

• Less than $25,000

• $25,000 to less than $35,000

• $35,000 to less than $50,000

• $50,000 to less than $75,000

• $75,000 or more

13. What category best describes your primary source of health care coverage? Please select one [BRFSS 2017]

• I don’t have health insurance coverage

• A plan provided through an employer or union (includes plans purchased through another person's employer)

• A plan that you or another family member buys on your/their own

• Medicare

• Medicaid

• TRICARE (formerly CHAMPUS), VA, or Military

• Alaska Native, Indian Health Service, Tribal Health Services

• Some other source

COMMUNITY CONTEXT

14. How long have you lived in your current community?

    • Less than a year

    • One to two years

    • Three to four years

    • More than five years

    • Five to ten years

15. Do you or a member of your household work in the energy industry (e.g. oil drilling, fracking, etc.)? This could include support roles, e.g. clerical work, driving a delivery truck, …)

• Yes, I work in the energy industry

• Yes, another member of my household works in the energy industry but I don’t

• Yes, myself and another member of my household works in the energy industry

• No

16. From the following list, what do you think are the three most important concerns in your community? Please select 3.

• Access to health care

• Access to healthy food

• Access to transportation

• Affordable housing

• Arts and cultural events

• Child abuse/neglect

• Clean environment

• Disease/death rates

• Jobs and economy

• Roads/infrastructure

• Schools/education

• Healthy behaviors/lifestyles

• Parks and recreation

• Community leadership

• Community cohesion

• Child Care

• Other, please specify: __________

HEALTH MEDIATORS AND OUTCOMES

17. Would you say that your general health is____? [BRFSS 2017]

• Excellent

• Very good

• Good

• Fair

• Poor

18. Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good? [BRFSS 2017]

• _______ Number of days

• None

19. Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good? [BRFSS 2017]

• _______ Number of days

• None

20. During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation? [BRFSS 2014]
    
    

• _______ Number of days

• None

21. A routine checkup is a general physical exam, not an exam for a specific injury, illness or condition. About how long has it been since you last visited a doctor for a routine checkup? [BRFSS 2017]

• Within the past year (anytime less than 12 months ago)

• Within the past 2 years (1 year but less than 2 years ago)

• Within the past 5 years (2 years but less than 5 years ago)

• 5 or more years ago

• NEVER

22. Please indicate if you have experienced the following issues as barriers to receiving medical care. Please check all that apply.

• Cost of care

• Transportation to/from care

• Distance to care provider

• Unsure where to go for care

• Lack of providers

• Lack of time due to work or family obligations

• Lack of insurance

23. Please indicate if you have experienced the following issues as barriers to receiving mental health care. Please check all that apply.

• Cost of care

• Transportation to/from care

• Distance to care provider

• Unsure where to go for care

• Lack of providers

• Lack of time due to work or family obligations

• Lack of insurance

BEHAVIORAL HEALTH

24. During the past 30 days, how many days per week or per month did you have at least one drink of any alcoholic beverage such as beer, wine, a malt beverage, or liquor? [BRFSS 2017]

• _____  Days per week

• _____  Days in past 30 days

• No drinks in past 30 days

25. Considering all types of alcoholic beverages, how many times during the past 30 days did you have 5 (FOR MEN) / 4 (FOR WOMEN) or more drinks on an occasion? [BRFSS 2014]

• _____ Number of times

• None

26. During the past 30 days, how many times have you driven when you’ve had perhaps too much to drink? [BRFSS 2014]

    • _____ Number of times

    • None

27. During the past 30 days, which of the following substances have you used? Please check all that apply [NSDUH 2014]

• Marijuana

• Pain relievers (non-medical use) (e.g. Oxycodone)

• Tranquilizers (non-medical use) (e.g. Xanax)

• Stimulants (e.g. meth)

• Cocaine / Crack

• Hallucinogens (e.g. LSD, ecstasy)

• Inhalants (e.g. markers, air duster)

• Heroin

• Sedatives (non-medical use) (e.g. Ambien, Lunesta)

About how often (all of the time, most of the time, some of the time, a little of the time, or none of the time) during the past 30 days did you feel… [BRFSS 2014]

	All of the time	most of the time	some of the time	a little of the time	None of the time
Nervous?					
Hopeless?					
Restless or fidgety?					
So depressed that nothing could cheer you up?					
That everything was an effort?					
Worthless?					

34. Have you thought seriously about killing yourself at any time during the past year? [NSDUH 2014]

• Yes

• No

SAFETY

35. In your community, which factors contribute to your feeling unsafe? Please check all that apply.

• Signage or information on streets

• Maintenance of public open spaces

• Bus stops or stations

• Gambling establishments

• Public restrooms

• Visible police or civil guards

• Strangers

• Homeless individuals

• Drug dealing

• Other, please specify: ______

• I feel safe

36. Which of the following factors affect your personal safety in your community? Please check all that apply.

• Being a woman

• Being of a certain religion

• Being of a certain race and/or ethnicity

• Being from another geographic area – region/state/country

• Having a certain sexual orientation

• Other, please specify: ________

• None

37. Which personal safety issues concern you the most in your community? Please check all that apply.

• Sexual harassment

• Verbal hassling

• Stalking

• Staring

• Whistling

• Sexual assault or rape

• Public disorderly conduct

• Public drunkenness

• Robbery or having money or other possessions stolen

• Kidnapping

• Forced labor

• Forced prostitution

• Drug trafficking and dealing

• Murder

• Other, please specify:______

38. Have you ever been the victim of violence in your household?

• Yes

• No

39. Have you ever been the victim of violence in the community where you currently live?

• Yes

• No

DRAFT – 09/13/16 14