0920-0572 Crisis Next Door Questionnaire

Form Approved

OMB No. 0920-0572

Exp. Date 8/31/2011

Attachment 3

Survey Questionnaire

Public reporting burden of this collection of information as 15 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 Information Collection Review Office, 1600 Clifton Road NE, SD-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0572).

EXPOSURE

Text in red and blue is not displayed to respondent.

Next, we would like you to watch a video ad from start to finish. Please watch the whole ad carefully. After watching the ad, we will ask you to answer questions about it

ADD ANY ADDITIONAL INSTRUCTIONS FOR RESPONDENT TO PLAY AD.

[RANDOMIZE RESPONDENTS TO CONTROL (NO AD) OR 1 OF 6 AD CONDITIONS BELOW].

	AD1	AD2	AD3	AD4	AD5	AD6
Video	Ashley	George	Sarah – FL	Sarah – MA	Rose	Mitchell
Intro	Ashley. This is Ashley’s story. About losing her sister to opioids.	George: This is George’s story. About recovering from addiction.	This is Sarah’s story. About her son’s struggle with opioid addiction.	This is Sarah’s story. About losing her parents to opioids.	Rose: This is Rose’s story. About losing her daughter to opioid addiction.	Mitchell. This is Mitchell’s story. About recovering from addiction.
Tone	Loss	Recovery	Recovery	Loss	Loss	Recovery
Main Message	The opioid crisis is all around you.	The opioid crisis is all around you	The opioid crisis is all around you.	Nearly 1 in 3 people know someone addicted top opioids.	Every day, 130 Americans died from an opioid overdose	More than 11 million people misused prescription opioids in 2017.
Testimonial	She died from an analogue of Fentanyl. And the detectives believe she obtained it over the internet. She left behind 2 boys. I miss her every day. I think of her every day.	Recovery is possible. I found my route through the 12 step support groups and I have a life today that I never thought would be possible.	My son is alive. He’s 8 months into recovery. When our eyes were opened, we realized he had a problem and if we didn’t find help for him, we would lose him.	Drug addiction, it doesn’t happen to bad people or good people or rich people or poor people. It just happens to people. And we need to make sure it doesn’t happen to anyone else.	My daughter battled opioid addiction for the last 3 years of her life. On Nov 19, 2017, she overdosed.	There was 5 years of active addiction. I had a couple of overdoses and reached out for help. To this day, I have 6 and a half months clean.

AdExp: RECORD AD RESPONDENT WAS SHOWN

• IF RESPONDENT IS RANDOMIZED TO CONTROL CONDITION, THEY BEGIN SURVEY ON OUTCOMES SECTION.

[SCREEN #10]

A1. Were you able to watch the ad all the way through?

• Yes [CONTINUE]

• No

IF A1=NO, ASK A1A. IF A1=YES, GO TO A1b.

[SCREEN #11]

A1a. Please try to watch the video again?

Were you able to watch the ad all the way through?

• Yes [CONTINUE]

• No [INELIGIBLEE]

[SCREEN #12]

A1b. Please go ahead and watch the video a second time all the way through.

ADD INSTRUCTIONS FOR PLAYING VIDEO SECOND TIME.

Were you able to watch the video a second time all the way through?

• Yes [CONTINUE]

• No [INELIGIBLEE]

RECALL OF MAIN MESSAGE

[SCREEN #13]

B2. Which of these messages do you remember being in the ad? CHECK ALL THAT APPLY.

RANDOMIZE ORDER

• Recovery from addiction is possible.

• Watch more stories at CrisisNextDoor.gov

• Opioid addiction can happen to anyone.

• Treatment for opioid addiction is available to anyone who wants it.

• SPECIFIC MESSAGE RESPONDENT SAW IN THE AD THEY WERE SHOWN. INSTRUCTIONS BELOW.

If ad = AD1 OR AD2 OR AD3: The opioid crisis is all around you.

If ad = AD4: Nearly 1 in 3 people know someone addicted to opioids.

If ad = AD5: Every day, 130 Americans die from an opioid overdose.

If ad = AD6: More than 11 million people misused prescription opioid in 2017.

EMOTIONAL RESPONSE TO AD

[RANDOMIZE EMOTIONS [EMOT1 – EMOT10] INTO C1-C10 AND RECORD ORDER. SHOW 5 PER SCREEN AND RECORD ORDER]

	EMOTIONS
EMOT1	Afraid
EMOT2	Worried
EMOT3	Irritated
EMOT4	Anxious
EMOT5	Sad
EMOT6	Angry
EMOT7	Hopeful
EMOT9	Supported

[SCREEN #14]

The next set of questions ask for your opinions about the emotions you felt after watching the ad. Please indicate how much you agree or disagree with each statement.

	After watching the ad, I felt….	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
C1
C2
C3
C4
C5

[SCREEN #15]

Please indicate how much you agree or disagree with each statement.

	After watching the ad, I felt….	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
C6
C7
C8

Ad Perceptions

	RANDOMIZE ORDER OF STATEMENTS [ADPERC_O1 –ADPERC_O12] ABOUT THE OVERALL AD BETWEEN D1 AND D12 AND RECORD ORDER.
ADPERC_O1	The ad told me something new.
ADPERC_O2	The ad grabbed my attention.
ADPERC_O3	The ad is worth remembering.
ADPERC_O4	The ad is convincing.
ADPERC_O5	The ad is believable.
ADPERC_O6	The ad is informative.
ADPERC_O7	The ad is powerful.
ADPERC_O8	The ad is meaningful to me.
ADPERC_O9	The ad is confusing.
ADPERC_O10	This ad is made for a person like me.
ADPERC_O11	This ad is effective.
ADPERC_O12	Overall, I liked this ad.

[SCREEN #15]

Now we’d like to know what you think about the ad. Please indicate how much you agree or disagree with each statement.

		Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
D1
D2
D3
D4
D5
D6

[SCREEN #16]

Please indicate how much you agree or disagree with each statement about the ad.

		Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
D7
D8
D9
D10
D11
D12

AD PERCEPTIONS 2

	RANDOMIZE ORDER OF STATEMENTS ABOUT INFORMATION IN ADS [ADPERC_I1 – ADPERC_I5] INTO D13-D17 AND RECORD ORDER.
ADPERC_I1	I trust the information in this ad.
ADPERC_I2	The information in the ad is common knowledge.
ADPERC_I3	I’ve heard the information in this ad many times before.
ADPERC_I4	The statistics in the ad are believable. [Only show for Ad Assignments 4-6]
ADPERC_I5	The information in the ad is credible.

[SCREEN #17]

Please indicate how much you agree or disagree with each statement about the ad.

		Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
D13
D14
D15
D16
D17

[SCREEN #18]

Now we’d like to know what you think about the personal story in the ad. Please indicate how much you agree or disagree with each statement.

	RANDOMIZE ORDER OF STATEMENTS ABOUT STORY IN ADS [ADPERC_S1 – ADPERC_S5] AND RECORD ORDER.
ADPERC_S1	I believe the personal story in the ad.
ADPERC_S2	I trust the person telling the story.
ADPERC_S3	I relate to the person telling the story.
ADPERC_S4	I do not like the person telling the story.
ADPERC_S5	I relate to the story that was shared.

		Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
D18
D19
D20
D21
D22

[SCREEN #19]

Please indicate how much you agree or disagree with this statement.

		Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
D23	Overall, I trust the information from the Crisis Next Door campaign.

REASONS FOR PERCEPTIONS

[SCREEN #20]

E1. You indicated that you [INSERT RESPONSE] that “The ad is effective.” What, in particular, made you feel this way?

[SCREEN #21]

E2. [Ask only for Ad Assignment 4-6] You indicated that you [INSERT RESPONSE] that “The statistic in the ad is believable”. What, in particular, made you feel this way?

[SCREEN #22]

E3. You indicated that you [INSERT RESPONSE] that “I relate to the person telling the story.” What, in particular, made you feel this way?

[SCREEN #23]

E4. You indicated that you [INSERT RESPONSE] that “Overall, I trust the information from the Crisis Next Door Campaign”. What, in particular, made you feel this way?

OPINIONS ON THE CAMPAIGN

[SCREEN #24]

F2. In your opinion, what would make the ad better? Please be specific. [Open Text]

[SCREEN #25]

F3. Who do you think is sponsoring the Crisis Next Door campaign? [Open Text]

[SCREEN #26]

F4. The ad does not indicate who is sponsoring the Crisis Next Door campaign. In your opinion, which of the following organizations would be the most credible sponsor of the campaign? SELECT ONLY ONE RESPONSE. [RANDOMIZE RESPONSE OPTIONS]

• The White House

• The Surgeon General of the United States

• A non-governmental organization

• A state health department

• Centers for Disease Control and Prevention

OUTCOMES

INTENTIONS

RANDOMIZE ORDER OF INTENTIONS QUESTIONS AND RECORD ORDER. [G1-G8]

[SCREEN #27]

After viewing this ad, how likely are you to do the following in the next month?

		Extremely unlikely						Extremely likely	Not Applicable
G1	Look for more information about addiction to opioids.	1	2	3	4	5	6	7
G2	Watch more stories on the Crisis Next Door website.	1	2	3	4	5	6	7
G3	Seek out more information about the risks of using opioids.	1	2	3	4	5	6	7
G4	Talk to a friend or family member about the risks of using opioids.	1	2	3	4	5	6	7
G5	Avoid taking opioids for medical reasons.	1	2	3	4	5	6	7
G6	Avoid taking opioids recreationally.	1	2	3	4	5	6	7
G7	Try to get help for someone I know who may be addicted to opioids.	1	2	3	4	5	6	7	99
G8	Talk to my doctor about my own use of opioids.	1	2	3	4	5	6	7	99

BELIEFS

RANDOMIZE ORDER OF BELIEF QUESTIONS [BEL_1 THROUGH BEL_16] INTO H1-H16.

BEL_1	Addiction to opioids is a serious problem in the United States.
BEL_2	Addiction to opioids is a serious problem in my community.
BEL_3	Addiction to opioids is a serious problem in my neighborhood.
BEL_4	Recovery from addiction to opioids is not truly possible.
BEL_6	Most people who try to quit using opioids on their own are successful.
BEL_7	Anyone can become addicted to opioids.
BEL_8	People addicted to opioids are just like me.
BEL_9	I could become addicted to opioids.
BEL_10	It’s easy to become addicted to opioids.
BEL_11	Based on the statistics I’ve seen about opioid addiction, it’s likely that someone I know is addicted.
BEL_12	Opioid addiction is a treatable medical condition.
BEL_15	Addiction is a choice.

[SCREEN #28]

The next set of questions ask for your opinions about opioids. Please indicate your level of agreement or disagreement with each statement.

	INSERT STATEMENTS BELOW AND RECORD ORDER.	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
H1
H2
H3
H4
H5
H6
H7
H8

[SCREEN #29]

Please indicate your level of agreement or disagreement with each statement.

	INSERT STATEMENTS BELOW AND RECORD ORDER.	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
H9
H10
H11
H12
H13
H14
H15

[SCREEN #30]

STIGMA

The next set of questions ask for your opinions about people who have become addicted to prescription pain medication. Please indicate your level of agreement or disagreement with each statement.

	RANDOMIZE QUESTION AND RECORD ORDER.	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
I1	People addicted to opioids are more dangerous than the general population.
I4	People who are addicted to opioids should be able to stop using them on their own.
I5	People who have recovered from having an addiction to opioids still can’t be trusted.
I7	Individuals who have become addicted to prescription opioids are to blame for the opioid epidemic in the United States.
I8	If I found out that a close friend had become addicted to prescription opioids would avoid him or her.

[SCREEN #31]

ATTITUDES TOWARD PEOPLE WITH OUD PART 1

The next set of questions ask for your opinions about people who have become addicted to opioids. Please indicate your level of agreement or disagreement with each statement.

	RANDOMIZE QUESTION ORDER J1-J7 AND RECORD ORDER.	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
J1	People addicted to opioids are to blame for their own addiction.
J3	People addicted to opioids are morally weak.
J4	Some people lack the self-discipline to use opioids without becoming addicted to them.
J5	I would be willing to have a person with an addiction to opioids marry into my family.
J6	I would feel comfortable working with someone who was addicted to opioids.
J7	I would be comfortable becoming friends with someone who was in treatment for addiction to opioids.

[SCREEN #32]

MESSAGE TESTING

Please rank order these messages from 1 (most motivating) to 5 (least motivating). Please place a 1 next to the message that motivates you the most to [insert behavior]. Then, rank order the remaining messages. The message that motivates you the least should receive 5.

Rank (1–[insert number])	Message
	11.8 million people in the past year have misused opioids
	Last year, 2.3 million people misused opioids for the first time
	Every 11 minutes someone in America dies from an opioid overdose
	Nearly one in three people know someone addicted to opioids
	Additional messages may be added.

₉ Prefer not to answer

REPEAT FOR EACH BEHAVIOR BELOW.

1. Look for more information about addiction to opioids.

2. Watch more stories on the Crisis Next Door website.

3. Seek out more information about the risks of using opioids.

4. Talk to a friend or family member about the risks of using opioids.

5. Avoid taking opioids for medical reasons

6. Avoid taking opioids recreationally.

7. Try to get help for someone I know who may be addicted to opioids.

8. Talk to my doctor about my own use of opioids.

EXPERIENCE WITH ADDICTION

[SCREEN #33]

K1. Do you know anyone who has ever had a problem with prescription opioids (pain pills) or an illegal opioid like heroin?

• Yes [Go to K2]

• No [Go to K3]

• Don’t know [Go to K2)

[SCREEN #34]

K2. Who do you know who has ever had a problem with prescription opioids (pain pills) or an illegal opioid like heroin? CHECK ALL THAT APPLY.

• My parent or stepparent

• My grandparent or step-grandparent

• My child or stepchild

• My sibling or stepsibling

• My aunt, uncle, cousin, niece/nephew

• My close friend

• An acquaintance or someone else you know more casually

• Other_____________________

[SCREEN #35]

K3. Have you ever experienced withdrawal symptoms or had trouble getting off an opioid?

• Yes

• No

• Don’t know

ADDITIONAL DEMOGRAPHICS

[SCREEN #36]

What is your zip code? __ ___ ___ ___ ___

[SCREEN #37]

How many children do you have?

• 0

• 1

• 2

• 3

• 4

• 5

• 6

• More than 6
  
  
  

[SCREEN #38]

Please list the age(s) of your child/children below, starting with the youngest child. If any of the boxes to not apply to you, please leave them blank.

Child # 1: ____ years old [REQUIRED UNLESS CHECKBOX SELECTED]
Child # 2: ____ years old [ONLY ALLOW ENTRY IF CHILD 1 FILLED OUT]
Child # 3: ____ years old [ONLY ALLOW ENTRY IF CHILD 2 FILLED OUT]
Child # 4: ____ years old [ONLY ALLOW ENTRY IF CHILD 3 FILLED OUT]

Child # 5: ____ years old [ONLY ALLOW ENTRY IF CHILD 3 FILLED OUT]

Child # 6: ____ years old [ONLY ALLOW ENTRY IF CHILD 3 FILLED OUT]

[SCREEN #39]

Which of the following best describes your marital status?

• Single, never married

• Married

• Living with partner

• Separated

• Divorced

• Widowed/Widower

• Civil partnership

• Prefer not to answer