Adult Survey

OMB Clearance Number: 2528-0337 

Expires: XX/XX/XXXX 

Attachment M.2: The Obesity & Type II Diabetes Risk Assessment Adult Survey Follow-up

If you require information to be presented in an accessible format or reasonable accommodations to participate in this study, please contact us with any specific requests by calling XXX-XXX-XXXX or emailing [email protected]. If you require language assistance to participate in this study, please contact us with any specific language assistance requests or needs.

 

 Paperwork Reduction Act Burden Statement 

This collection of information is voluntary and will be used to evaluate the US Department of Housing and Urban Development’s Community Choice Demonstration. Public reporting burden for this collection of information is estimated to average 60 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, 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. The OMB number for this collection is OMB 2528-0337 which expires on XX/XX/XXXX. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to NAME at [email protected] or call XXX-XXX-XXXX.  

 

Privacy Act Statement 

Authority:  Section 502 of the Housing and Urban Development Act of 1970 (Public Law 91-609) (12 U.S.C. §§ 1701z-1; 1701z-2(d) and (g)). 

Purpose:  This information is being collected to evaluate changes in the housing quality and health and well-being of families who enrolled in the Community Choice Demonstration (CCD). Data collection will occur between January 2024 and June 2027.

Routine Use:  Please refer to System of Record Notice. 

Disclosure:  Your participation in this information collection is voluntary and you can choose not to answer any question that is asked. Your responses will not affect your current or future receipt of housing assistance or other benefits. Some study activities are being funded by the National Institute of Diabetes and Digestive and Kidney Diseases. 

SORN ID:  Housing Choice Voucher (HCV) Mobility Demonstration Evaluation Data Files, PD&R/RRE 09 

 

MOVED ADULT FOLLOW-UP SURVEY

Introduction

Thank you for taking the time to meet with me today. This survey will cover several topics that will help us understand how neighborhood may impact adult health outcomes, like obesity and (type II) diabetes. The survey will cover topics like diet, neighborhood, and exercise. None of the questions asked will be used for diagnostic purposes. Participation is completely voluntary and you may choose to skip any questions that you do not wish to answer. The interview should take about 60 minutes to complete. You can choose not to answer any question. Are you ready to begin the survey now?

PHYSICAL ACTIVITY

The first set of questions asks about the different types of activities you may do and where you may do them.[if needed: if you feel that these questions are too personal, you can choose not to answer them.]

International Physical Activity Questionnaire Short Form

Vigorous activity

Think about all the vigorous activities that you did in the last 7 days. Vigorous physical activities refer to activities that take hard physical effort and make you breathe much harder than normal. Think only about those physical activities that you did for at least 10 minutes at a time.

1. During the last 7 days, on how many days did you do vigorous physical activities like heavy lifting, digging, aerobics, or fast bicycling?

[Source: International Physical Activity Questionnaire - Short Form; https://youthrex.com/wp-content/uploads/2019/10/IPAQ-TM.pdf]

1. # of days per week

2. No vigorous physical activity [SKIP TO MODERATE ACTIVITY]

3. Don’t know/not sure

4. Prefer not to answer

2. [IF AT LEAST 1 DAY PER WEEK] How much time did you usually spend doing vigorous physical activities on one of those days?

[Source: International Physical Activity Questionnaire - Short Form; https://youthrex.com/wp-content/uploads/2019/10/IPAQ-TM.pdf]

1. X hours per day

2. X minutes per day

3. Don’t know/not sure

4. Prefer not to answer

Moderate activity

Think about all the moderate activities that you did in the last 7 days. Moderate activities refer to activities that take moderate physical effort and make you breathe somewhat harder than normal. Think only about those physical activities that you did for at least 10 minutes at a time.

1. During the last 7 days, on how many days did you do moderate physical activities like carrying light loads, bicycling at a regular pace, or doubles tennis? Do not include walking.

[Source: International Physical Activity Questionnaire - Short Form; https://youthrex.com/wp-content/uploads/2019/10/IPAQ-TM.pdf]

1. # of days per week

2. No moderate physical activity [SKIP TO WALKING]

3. Don’t know/not sure

4. Prefer not to answer

2. [IF AT LEAST 1 DAY PER WEEK] How much time did you usually spend doing moderate physical activities on one of those days?

[Source: International Physical Activity Questionnaire - Short Form; https://youthrex.com/wp-content/uploads/2019/10/IPAQ-TM.pdf]

1. X hours per day

2. X minutes per day

3. Don’t know/not sure

4. Prefer not to answer

Walking

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 have done solely for recreation, sport, exercise, or leisure.

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

[Source: International Physical Activity Questionnaire - Short Form; https://youthrex.com/wp-content/uploads/2019/10/IPAQ-TM.pdf]

1. # of days per week

2. No moderate physical activity [SKIP TO SITTING]

3. Don’t know/not sure

4. Prefer not to answer

2. [IF AT LEAST 1 DAY PER WEEK] How much time did you usually spend walking on one of those days?

[Source: International Physical Activity Questionnaire - Short Form; https://youthrex.com/wp-content/uploads/2019/10/IPAQ-TM.pdf]

1. X hours per day

2. X minutes per day

3. Don’t know/not sure

4. Prefer not to answer

Sitting

The last question is about the time you spent sitting on weekdays during the last 7 days. Include time spent at work, at home, while doing course work and during leisure time. This may include time spent sitting at a desk, visiting friends, reading, or sitting or lying down to watch television.

1. During the last 7 days, how much time did you spend sitting on a weekday?

[Source: International Physical Activity Questionnaire - Short Form; https://youthrex.com/wp-content/uploads/2019/10/IPAQ-TM.pdf]

1. X hours per day

2. X minutes per day

3. Don’t know/not sure

4. Prefer not to answer

Location of physical activity

1. In the past month, where have you gone most often for physical activity? [ONE PLACE RESPONDENT PREFERS TO GO TO MOST OFTEN]

[Source: RAND Corporation’s PHRESH Survey (Pittsburgh Hill/Homewood Research On Neighborhood Change and Health]

1. Park

2. Trail or another walking/running path

3. Gym/recreation center

4. Your own home

5. Home of a family member or a friend

6. Work

7. Retail outlets (malls)

8. Streets/sidewalks

9. Physical therapy or rehabilitation

10. Other (please specify type of place)

11. I don't engage in physical activity

12. I don't know

13. Prefer not to answer

2. In the past month, how often did you walk to places in your neighborhood for exercise, pleasure, or to get somewhere you needed to go?

[Source: RAND Corporation’s PHRESH Survey (Pittsburgh Hill/Homewood Research On Neighborhood Change and Health]

1. At least once a day in the past month

2. 3-6 times a week in the past month

3. Once or twice a week in the past month

4. 2-3 times in the past month

5. Once I the past month

6. Never in the past month

7. Don't know

8. Prefer not to answer

DIET

The next set of questions I have are about the different types of food people eat. We want to know which of these foods you eat. [if needed: if you feel that these questions are too personal, you can choose not to answer them.]

NCI Dietary Screener

1. During the past month, how often did you eat hot or cold cereals? You can tell me per day, per week, or per month.

___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS

1. Never (Go to Q4)

2. Don’t know

3. Prefer not to answer

Enter unit

1. Day

2. Week

3. Month

4. Don't know

5. Prefer not to answer

[Source: NCI Dietary Screener; https://epi.grants.cancer.gov/diet/shortreg/instruments/dsq-in-nhanes-09-10-interviewer-administered-english-version.pdf]

2. [SKIP IF 1=A or prefer not to answer] During the past month, what kind of cereal did you usually eat?

   1. [OPEN RESPONSE]

   2. Don’t know

   3. Prefer not to answer

[Source: NCI Dietary Screener; https://epi.grants.cancer.gov/diet/shortreg/instruments/dsq-in-nhanes-09-10-interviewer-administered-english-version.pdf]

3. [SKIP IF 1=A or prefer not to answer] If there was another kind of cereal that you usually ate during the past month, what kind was it?

   1. [OPEN RESPONSE]

   2. Don’t know

   3. Prefer not to answer

[Source: NCI Dietary Screener; https://epi.grants.cancer.gov/diet/shortreg/instruments/dsq-in-nhanes-09-10-interviewer-administered-english-version.pdf]

4. During the past month, how often did you drink regular soda or pop that contains sugar? Do not include diet soda. You can tell me per day, per week, or per month.

[Source: NCI Dietary Screener; https://epi.grants.cancer.gov/diet/shortreg/instruments/dsq-in-nhanes-09-10-interviewer-administered-english-version.pdf]

___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS

1. Never

2. Don’t know

3. Prefer not to answer

Enter unit

6. Day

7. Week

8. Month

9. Don't know

10. Prefer not to answer

5. During the past month, how often did you drink 100% pure fruit juices such as orange, mango, apple, grape and pineapple juices? Do not include fruit-flavored drinks with added sugar or fruit juice you made at home and added sugar to. (You can tell me per day, per week, or per month.)

[Source: NCI Dietary Screener; https://epi.grants.cancer.gov/diet/shortreg/instruments/dsq-in-nhanes-09-10-interviewer-administered-english-version.pdf]

___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS

1. Never

2. Don’t know

3. Prefer not to answer

Enter unit

1. Day

2. Week

3. Month

4. Don't know

5. Prefer not to answer

6. (During the past month), how often did you drink coffee or tea that had sugar or honey added to it? Include coffee and tea you sweetened yourself and presweetened tea and coffee drinks such as Arizona Iced Tea and Frappuccino. Do not include artificially sweetened coffee or diet tea. (You can tell me per day, per week, or per month.)

[Source: NCI Dietary Screener; https://epi.grants.cancer.gov/diet/shortreg/instruments/dsq-in-nhanes-09-10-interviewer-administered-english-version.pdf]

___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS

1. Never

2. Don’t know

3. Prefer not to answer

Enter unit

1. Day

2. Week

3. Month

4. Don’t’ know

5. Prefer not to answer

7. (During the past month), how often did you drink sweetened fruit drinks, sports or energy drinks, such as Kool-Aid, lemonade, Hi-C, cranberry drink, Gatorade, Red Bull, or Vitamin Water? Include fruit juices you made at home and added sugar to. Do not include diet drinks or artificially sweetened drinks. (You can tell me per day, per week, or per month.)

[Source: NCI Dietary Screener; https://epi.grants.cancer.gov/diet/shortreg/instruments/dsq-in-nhanes-09-10-interviewer-administered-english-version.pdf]

___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS

1. Never

2. Don’t know

3. Prefer not to answer

Enter unit

1. Day

2. Week

3. Month

4. Don’t know

5. Refused

8. (During the past month), how often did you eat fruit? Include fresh, frozen or canned fruit. Do not include juices. (You can tell me per day, per week, or per month.)

[Source: NCI Dietary Screener; https://epi.grants.cancer.gov/diet/shortreg/instruments/dsq-in-nhanes-09-10-interviewer-administered-english-version.pdf]

___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS

1. Never

2. Don’t know

3. Prefer not to answer

Enter unit

1. Day

2. Week

3. Month

4. Don't know

5. Prefer not to answer

9. (During the past month), how often did you eat a green leafy or lettuce salad, with or without other vegetables? (You can tell me per day, per week, or per month.)

[Source: NCI Dietary Screener; https://epi.grants.cancer.gov/diet/shortreg/instruments/dsq-in-nhanes-09-10-interviewer-administered-english-version.pdf]

___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS

1. Never

2. Don’t know

3. Prefer not to answer

Enter unit

1. Day

2. Week

3. Month

4. Don’t know

5. Prefer not to answer

10. (During the past month), how often did you eat any kind of fried potatoes, including french fries, home fries, or hash brown potatoes? (You can tell me per day, per week, or per month.)

[Source: NCI Dietary Screener; https://epi.grants.cancer.gov/diet/shortreg/instruments/dsq-in-nhanes-09-10-interviewer-administered-english-version.pdf]

___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS

1. Never

2. Don’t know

3. Prefer not to answer

Enter unit

1. Day

2. Week

3. Month

4. Don’t know

5. Prefer not to answer

11. (During the past month), how often did you eat any kind of potatoes, such as baked, boiled, mashed potatoes, sweet potatoes, or potato salad? (You can tell me per day, per week, or per month.)

[Source: NCI Dietary Screener; https://epi.grants.cancer.gov/diet/shortreg/instruments/dsq-in-nhanes-09-10-interviewer-administered-english-version.pdf]

___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS

1. Never

2. Don’t know

3. Prefer not to answer

Enter unit

1. Day

2. Week

3. Month

4. Don’t know

5. Prefer not to answer

12. (During the past month), how often did you eat refried beans, baked beans, beans in soup, pork and beans or any other type of cooked dried beans? Do not include green beans. (You can tell me per day, per week, or per month.)

[Source: NCI Dietary Screener; https://epi.grants.cancer.gov/diet/shortreg/instruments/dsq-in-nhanes-09-10-interviewer-administered-english-version.pdf]

___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS

1. Never

2. Don’t know

3. Prefer not to answer

Enter unit

1. Day

2. Week

3. Month

4. Don’t know

5. Prefer not to answer

13. (During the past month), how often did you eat brown rice or other cooked whole grains, such as bulgur, cracked wheat or millet? Do not include white rice. (You can tell me per day, per week, or per month.)

[Source: NCI Dietary Screener; https://epi.grants.cancer.gov/diet/shortreg/instruments/dsq-in-nhanes-09-10-interviewer-administered-english-version.pdf]

___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS

1. Never

2. Don’t know

3. Prefer not to answer

Enter unit

1. Day

2. Wek

3. Month

4. Don’t know

5. Prefer not to answer

14. (During the past month), not including what you just told me about--green salads, potatoes, cooked dried beans--how often did you eat other vegetables? (You can tell me per day, per week, or per month.)

[Source: NCI Dietary Screener; https://epi.grants.cancer.gov/diet/shortreg/instruments/dsq-in-nhanes-09-10-interviewer-administered-english-version.pdf]

___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS

1. Never

2. Don’t know

3. Prefer not to answer

Enter unit

1. Day

2. Week

3. Month

4. Don’t know

5. Prefer not to answer

15. (During the past month), how often did you have Mexican-type salsa made with tomato? (You can tell me per day, per week, or per month.)

[Source: NCI Dietary Screener; https://epi.grants.cancer.gov/diet/shortreg/instruments/dsq-in-nhanes-09-10-interviewer-administered-english-version.pdf]

___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS

1. Never

2. Don’t know

3. Prefer not to answer

Enter unit

1. Day

2. Week

3. Month

4. Don’t know

5. Prefer not to answer

16. (During the past month), how often did you eat pizza? Include frozen pizza, fast food pizza, and homemade pizza. (You can tell me per day, per week, or per month.)

[Source: NCI Dietary Screener; https://epi.grants.cancer.gov/diet/shortreg/instruments/dsq-in-nhanes-09-10-interviewer-administered-english-version.pdf]

___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS

1. Never

2. Don’t know

3. Prefer not to answer

Enter unit

1. Day

2. Week

3. Month

4. Don’t know

5. Prefer not to answer

17. (During the past month), how often did you have tomato sauces such as with spaghetti or noodles or mixed into foods such as lasagna? Do not include tomato sauce on pizza. (You can tell me per day, per week, or per month.)

[Source: NCI Dietary Screener; https://epi.grants.cancer.gov/diet/shortreg/instruments/dsq-in-nhanes-09-10-interviewer-administered-english-version.pdf]

___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS

1. Never

2. Don’t know

3. Prefer not to answer

Enter unit

1. Day

2. Week

3. Month

4. Don’t know

5. Prefer not to answer

18. (During the past month), how often did you eat any kind of cheese? Include cheese as a snack, cheese on burgers, sandwiches, and cheese in foods such as lasagna, quesadillas, or casseroles. Do not include cheese on pizza. (You can tell me per day, per week, or per month.)

[Source: NCI Dietary Screener; https://epi.grants.cancer.gov/diet/shortreg/instruments/dsq-in-nhanes-09-10-interviewer-administered-english-version.pdf]

___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS

1. Never

2. Don’t know

3. Prefer not to answer

Enter unit

1. Day

2. Week

3. Month

4. Don’t know

5. Prefer not to answer

19. Please look at this card, during the past month, how often did you eat red meat such as beef, pork, ham, or sausage? Do not include chicken, turkey or seafood. (You can tell me per day, per week, or per month.)

SEE CARD ON PAGE 20: https://www.cdc.gov/nchs/data/nhanes/nhanes_09_10/sp_handcards_0910.pdf

[Source: NCI Dietary Screener; https://epi.grants.cancer.gov/diet/shortreg/instruments/dsq-in-nhanes-09-10-interviewer-administered-english-version.pdf]

___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS

1. Never

2. Don’t know

3. Prefer not to answer

Enter unit

1. Day

2. Week

3. Month

4. Don’t know

5. Prefer not to answer

20. Please look at this card, (during the past month), how often did you eat any processed meat, such as bacon, lunch meats, or hot dogs? (You can tell me per day, per week, or per month.)

SEE CARD ON PAGE 21: https://www.cdc.gov/nchs/data/nhanes/nhanes_09_10/sp_handcards_0910.pdf

[Source: NCI Dietary Screener; https://epi.grants.cancer.gov/diet/shortreg/instruments/dsq-in-nhanes-09-10-interviewer-administered-english-version.pdf]

___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS

1. Never

2. Don’t know

3. Prefer not to answer

Enter unit

1. Day

2. Week

3. Month

4. Don’t know

5. Prefer not to answer

21. (During the past month), how often did you eat whole grain bread including toast, rolls and in sandwiches? Whole grain breads include whole wheat, rye, oatmeal and pumpernickel. Do not include white bread. (You can tell me per day, per week, or per month.)

HAND CARD DTQ3 on page 22: https://www.cdc.gov/nchs/data/nhanes/nhanes_09_10/sp_handcards_0910.pdf

[Source: NCI Dietary Screener; https://epi.grants.cancer.gov/diet/shortreg/instruments/dsq-in-nhanes-09-10-interviewer-administered-english-version.pdf]

___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS

1. Never

2. Don’t know

3. Prefer not to answer

Enter unit

1. Day

2. Week

3. Month

4. Don’t know

5. Prefer not to answer

22. During the past month, how often did you eat chocolate or any other types of candy? Do not include sugar-free candy.

[Source: NCI Dietary Screener; https://epi.grants.cancer.gov/diet/shortreg/instruments/dsq-in-nhanes-09-10-interviewer-administered-english-version.pdf]

___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS

1. Never

2. Don’t know

3. Prefer not to answer

Enter unit

1. Day

2. Week

3. Month

4. Don’t know

5. Prefer not to answer

23. (During the past month), how often did you eat doughnuts, sweet rolls, Danish, muffins, pan dulce, or pop-tarts? Do not include sugar-free items. (You can tell me per day, per week, or per month.)

[Source: NCI Dietary Screener; https://epi.grants.cancer.gov/diet/shortreg/instruments/dsq-in-nhanes-09-10-interviewer-administered-english-version.pdf]

___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS

1. Never

2. Don’t know

3. Prefer not to answer

Enter unit

1. Day

2. Week

3. Month

4. Don’t know

5. Prefer not to answer

24. (During the past month), how often did you eat cookies, cake, pie, or brownies? Do not include sugar-free kinds. (You can tell me per day, per week, or per month.)

[Source: NCI Dietary Screener; https://epi.grants.cancer.gov/diet/shortreg/instruments/dsq-in-nhanes-09-10-interviewer-administered-english-version.pdf]

___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS

1. Never

2. Don’t know

3. Prefer not to answer

Enter unit

1. Day

2. Week

3. Month

4. Don’t know

5. Prefer not to answer

25. (During the past month), how often did you eat ice cream or other frozen desserts? Do not include sugar-free kinds. (You can tell me per day, per week, or per month.)

[Source: NCI Dietary Screener; https://epi.grants.cancer.gov/diet/shortreg/instruments/dsq-in-nhanes-09-10-interviewer-administered-english-version.pdf]

___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS

1. Never

2. Don’t know

3. Prefer not to answer

Enter unit

1. Day

2. Week

3. Month

4. Don’t know

5. Prefer not to answer

26. (During the past month), how often did you eat popcorn? (You can tell me per day, per week, or per month.)

[Source: NCI Dietary Screener; https://epi.grants.cancer.gov/diet/shortreg/instruments/dsq-in-nhanes-09-10-interviewer-administered-english-version.pdf]

___ ENTER QUANTITY IN DAYS, WEEKS, OR MONTHS

1. Never

2. Prefer not to answer

3. Don’t know

Enter unit

1. Day

2. Week

3. Month

4. Don’t know

5. Prefer not to answer

Eating out

1. Next I'm going to ask you about meals. By meal, I mean breakfast, lunch and dinner. During the past 7 days, how many meals did you get that were prepared away from home in places such as restaurants, fast food places, food stands, grocery stores, or from vending machines?

[Source: Frequency of Eating Out and Cooking At Home (NHANES)]

1. None

2. [ENTER NUMBER 1-21]

3. More than 21 times

4. Don’t know

5. Prefer not to answer

2. [if 1 is not none, DK, refused] How many of those meals did you get from a fast-food or pizza place?

[Source: Frequency of Eating Out and Cooking At Home (NHANES)]

1. [ENTER NUMBER 1-21]

2. None

3. More than 21 times

4. Don’t know

5. Prefer not to answer

Body satisfaction

I’m now going to ask you a few questions about how you feel about your body.

1. On a scale from 1 to 10, where 1 is “Extremely Unsatisfied” and 10 is “Extremely Satisfied”, how satisfied are you with your weight?

[Source: Does Body Satisfaction Matter?; https://pubmed.ncbi.nlm.nih.gov/16857537/]

[Scale from 1 to 10]

Don’t know

Prefer not to answer

2. On a scale from 1 to 10, where 1 is “Extremely Unsatisfied” and 10 is “Extremely Satisfied”, how satisfied are you with your body shape?

[Source: Does Body Satisfaction Matter?; https://pubmed.ncbi.nlm.nih.gov/16857537/]

[Scale from 1 to 10]

Don’t know

Prefer not to answer

Diet behaviors

Now I’d like to ask some questions about your diet behavior.

1. How often have you gone on a diet during the last year? By 'diet' we mean changing the way you eat so you can lose weight.

[Source: Dieting and disordered eating behaviors among adolescents; https://www-sciencedirect-com.proxy1.library.jhu.edu/science/article/pii/S0002822311004251]

6. Never

7. One to four times

8. Five to ten times

9. More than ten times

10. I am always dieting

11. Don’t know

12. Prefer not to answer

2. Have you done any of the following things in order to lose weight or keep from gaining weight during the past year including fasting, ate very little food, took diet pills, made yourself vomit, used laxatives, used diuretics (water pills), used food substitute (powder or special drinks), skipped meals, or smoked more cigarettes?

[Source: https://www.sph.umn.edu/sph-2018/wp-content/uploads/2019/12/project-eat-gen2-adolescent-survey.pdf]

1. Yes

2. No

3. Don’t know

4. Prefer not to answer

3. In the past year, have you ever eaten so much food in a short period of time that you would be embarrassed if others saw you (binge-eating)?

[Source: https://www.sph.umn.edu/sph-2018/wp-content/uploads/2019/12/project-eat-gen2-adolescent-survey.pdf]

1. Yes

2. No

3. Don’t know

4. Prefer not to answer

4. [if question 3=a] During the times when you ate this way, did you feel like you couldn’t stop eating or control what or how much you were eating?

[Source: https://www.sph.umn.edu/sph-2018/wp-content/uploads/2019/12/project-eat-gen2-adolescent-survey.pdf]

1. Yes

2. No

3. Don’t know

4. Prefer not to answer

Eating to cope

1. In the past 12 months, how often have you eaten… [Never, rarely, sometimes, always, often]

[Source: Motivations to Eat subscale; Depression; https://www-sciencedirect-com.proxy1.library.jhu.edu/science/article/pii/S0092656602005743]

1. Because you’re depressed or sad

2. Because you feel worthless or inadequate

3. As a way to help you cope

4. As a way to comfort yourself

5. As a way to avoid thinking about something unpleasant to distract yourself

1. Never

2. Rarely

3. Sometimes

4. Always

5. Often

6. Don’t know

7. Prefer not to answer

Experienced weight stigma

1. Have you ever been [READ EACH BELOW] because of your weight? [YES OR NO]

[Source: Experienced Stigma Scale; https://pubmed-ncbi-nlm-nih-gov.proxy1.library.jhu.edu/34061867/.]

1. Teased

2. Treated unfairly

3. Discriminated against

1. Yes

2. No

3. Don’t know

4. Prefer not to answer

Food security

I’m going to read you several statement that people have made about their food situation. For these statements, please tell me whether the statement was often true, sometimes true, or never true for your household in the last 12 months – that is, since last [NAME OF CURRENT MONTH].

[if needed: Some people may find the next few questions personal. Please remember you can choose not to answer any question.]

1. The first statement is, “The food that we bought just didn’t last, and we didn’t have money to get more.” Was this often, sometimes, or never true for your household?

[Source: NHANES; https://www.ers.usda.gov/media/8282/short2012.pdf]

1. Often true

2. Sometimes true

3. Never true

4. Don’t know

5. Prefer not to answer

2. “We couldn’t afford to eat balanced meals.” Was that often, sometimes, or never true for your household in the last 12 months?

[Source: NHANES; https://www.ers.usda.gov/media/8282/short2012.pdf]

1. Often true

2. Sometime true

3. Never true

4. Don’t know

5. Prefer not to answer

3. In the last 12 months, since last [NAME OF CURRENT MONTH] did you or other adults in your household ever cut the size of your meals or skip meals because there wasn’t enough money for food?

[Source: NHANES; https://www.ers.usda.gov/media/8282/short2012.pdf]

1. Yes

2. No (skip)

3. Don’t know (skip)

4. Prefer not to answer skip 4)

4. [IF 3=A] How often did this happen – almost every month, some months but not every month, or in only 1 or 2 months?

[Source: NHANES; https://www.ers.usda.gov/media/8282/short2012.pdf]

1. Almost every month

2. Some months but not every month

3. Only 1 or 2 months

4. Don’t know

5. Prefer not to answer

5. In the last 12 months, did you ever eat less than you felt you should because there wasn’t enough money for food?

[Source: NHANES; https://www.ers.usda.gov/media/8282/short2012.pdf]

1. Yes

2. No

3. Don’t know

4. Prefer not to answer

6. In the last 12 months, were you ever hungry but didn’t eat because there wasn’t enough money for food?

[Source: NHANES; https://www.ers.usda.gov/media/8282/short2012.pdf]

1. Yes

2. No

3. Don’t know

4. Prefer not to answer

NEIGHBORHOOD FOOD ENVIRONMENT

Please tell me how you agree with each of the following statements. [if needed: if you feel that these questions are too personal, you can choose not to answer them.]

1. It is easy to buy fresh fruits and vegetables in my neighborhood.

[Source: Green, S. & Glanz, K. (2015). Development of the Perceived Nutrition Environment Measures Survey. American Journal of Preventative Medicine.]

1. Strongly disagree

2. Somewhat disagree

3. Neither agree nor disagree

4. Somewhat agree

5. Strongly agree

6. Don’t know

7. Prefer not to answer

2. The fresh produce in my neighborhood is of high quality.

[Source: Green, S. & Glanz, K. (2015). Development of the Perceived Nutrition Environment Measures Survey. American Journal of Preventative Medicine.]

1. Strongly disagree

2. Somewhat disagree

3. Neither agree nor disagree

4. Somewhat agree

5. Strongly agree

6. Don’t know

7. Prefer not to answer

3. Fresh fruit and vegetables in my neighborhood are expensive.

[Source: Green, S. & Glanz, K. (2015). Development of the Perceived Nutrition Environment Measures Survey. American Journal of Preventative Medicine.]

1. Strongly disagree

2. Somewhat disagree

3. Neither agree nor disagree

4. Somewhat agree

5. Strongly agree

6. Don’t know

7. Prefer not to answer

4. What type of store is the store where you buy most of your food? Choose the best answer.

[Source: Green, S. & Glanz, K. (2015). Development of the Perceived Nutrition Environment Measures Survey. American Journal of Preventative Medicine.]

1. Supermarket

2. Small grocery store

3. Corner store or convenience store

4. Supercenter (like Wal-Mart or Costco)

5. Other (please specify):

6. Don’t know

7. Prefer not to answer

5. Thinking about the store where you buy most of your food, how do you usually travel to this store?

[Source: Green, S. & Glanz, K. (2015). Development of the Perceived Nutrition Environment Measures Survey. American Journal of Preventative Medicine.]

1. Walk

2. Bicycle

3. Bus or other public transportation

4. Drive your own car

5. Get a ride

6. Other (please specify):

7. Don’t know

8. Prefer not to answer

6. About how long does it take to get from your home to the store where you buy most of your food?

[Source: Green, S. & Glanz, K. (2015). Development of the Perceived Nutrition Environment Measures Survey. American Journal of Preventative Medicine.]

1. 10 minutes or less

2. 11 to 20 minutes

3. 21 to 30 minutes

4. More than 30 minutes

5. Don’t know

6. Prefer not to answer

SLEEP

The following questions relate to your usual sleep habits during the past month only. Your answers should indicate the most accurate reply for the majority of days and nights in the past month. [if needed: if you feel that these questions are too personal, you can choose not to answer them.]

1. During the past month, what time have you usually gone to bed at night?

[Source: Sancho-Domingo, C., Carballo, J., Caloma-Carmona, A., & Buysse, D. (2021). Brief version of the Pittsburgh Sleep Quality Index (B-PSQI) and measurement invariance across gender and age in a population-based sample. Psychological Assessment.]

1. Bedtime AM/PM: [OPEN RESPONSE]

2. Don't know

3. Prefer not to answer

2. During the past month, how long (in minutes) does it usually take you to fall asleep each night?

[Source: Sancho-Domingo, C., Carballo, J., Caloma-Carmona, A., & Buysse, D. (2021). Brief version of the Pittsburgh Sleep Quality Index (B-PSQI) and measurement invariance across gender and age in a population-based sample. Psychological Assessment.]

1. Number of minutes:

2. Don't know

3. Prefer not to answer

3. During the past month, what time have you usually gotten up in the morning?

[Source: Sancho-Domingo, C., Carballo, J., Caloma-Carmona, A., & Buysse, D. (2021). Brief version of the Pittsburgh Sleep Quality Index (B-PSQI) and measurement invariance across gender and age in a population-based sample. Psychological Assessment.]

1. GETTING UP TIME: AM/PM

2. Don’t know

3. Prefer not to answer
   
   

1. During the past month, how would you rate your sleep quality overall?

[Source: Sancho-Domingo, C., Carballo, J., Caloma-Carmona, A., & Buysse, D. (2021). Brief version of the Pittsburgh Sleep Quality Index (B-PSQI) and measurement invariance across gender and age in a population-based sample. Psychological Assessment.]

1. Very good

2. Fairly good

3. Fairly bad

4. Very bad

5. Don’t know

6. Prefer not to answer

TRANSPORTATION

The next set of questions are about different ways people may get from place to place in your neighborhood and how you get around. [if needed: if you feel that these questions are too personal, you can choose not to answer them.]

Mode of transportation

1. What is the most common way that you get around?

[Source: Local survey by Sabriya Linton on Baltimore HOPE VI redevelopment]

1. Motorized vehicle (e.g., car, truck) that belongs to me

2. Motorized vehicle (e.g., car, truck) that you borrow from someone else

3. Motorized vehicle (e.g., car, truck) that you rent

4. Catch a ride with a friend or relative

5. Public transportation

6. Taxi, Uber, Lyft (other rideshare apps)

7. Walk

8. Bicycle

9. Other:

10. Don’t know

11. Prefer not to answer

NEIGHBORHOOD WALKABILITY

How much would you agree or disagree with the following statements about your neighborhood? The choices are: strongly agree, agree, neither agree nor disagree, disagree or strongly disagree. [if needed: if you feel that these questions are too personal, you can choose not to answer them.]

1. There are many places to go within walking distance of my home.

[Source: https://www.ipenproject.org/documents/publications_docs/NEWS%20and%20NEWS-A.pdf]

1. Strongly agree

2. Agree

3. Neutral (neither agree nor disagree)

4. Disagree

5. Strongly disagree

6. Don’t know

7. Prefer not to answer

2. My neighborhood offers many opportunities to be physically active.

[Source: https://academic.oup.com/aje/article/165/8/858/185012]

1. Strongly agree

2. Agree

3. Neutral (neither agree nor disagree)

4. Disagree

5. Strongly disagree

6. Don’t know

7. Prefer not to answer

3. It is pleasant to walk in my neighborhood.

[Source: https://academic.oup.com/aje/article/165/8/858/185012]

1. Strongly agree

2. Agree

3. Neutral (neither agree nor disagree)

4. Disagree

5. Strongly disagree

6. Don’t know

7. Prefer not to answer

4. I often see other people walking in my neighborhood.

[Source: https://academic.oup.com/aje/article/165/8/858/185012]

1. Strongly agree

2. Agree

3. Neutral (neither agree nor disagree)

4. Disagree

5. Strongly disagree

6. Don’t know

7. Prefer not to answer

Public transport

Next,

1. How many days a week do you make use of public transportation?

[Source: Massey, Climbing Mount Laurel study]

1. 1-7 days

2. I don’t use public transportation

3. Don’t know

4. Prefer not to answer

2. How long would it take you to get to the nearby bus, train, or subway stop?

[Source: Massey, Climbing Mount Laurel study]

1. < 15mins

2. 15 to 30 mins

3. 31 to 45 mins

4. 46 min to 1 hour

5. > 1 hour

6. N/A

7. Don’t know

8. Prefer not to answer

3. How good is the public transportation service in your neighborhood?

[Source: Massey, Climbing Mount Laurel study]

1. Very poor

2. Poor

3. Good

4. Very good

5. Don’t know

6. Prefer not to answer

Motor vehicle access

1. Do you presently own a motor vehicle?

[Source: Massey, Climbing Mount Laurel study]

1. Yes

2. No

3. Don't know

4. Prefer not to answer

2. [IF 1 NOT a] Do you have reliable access to a vehicle?

[Source: Massey, Climbing Mount Laurel study]

1. Yes

2. No

3. Don't know

4. Prefer not to answer

HEALTH LIMITING MOVING

Changing topics…

1. Would the health of anyone in your household prevent you from moving to a new neighborhood? [if needed: if you feel that these questions are too personal, you can choose not to answer them.]

[Source: New question]

1. Yes

2. No

3. Don’t know

4. Prefer not to answer

HEALTHCARE

Now I’d like to talk a bit about health insurance and health care. [if needed: if you feel that these questions are too personal, you can choose not to answer them.]

Insurance

1. Are you covered by any health insurance or some other kind of health care plan?

[Source: National Health Interview Survey]

1. Yes

2. No

3. Don’t know

4. Prefer not to answer

2. [If q1 does not = b] What kinds of health insurance or health care coverage do you have?

[Source: National Health Interview Survey]

1. Private health insurance

2. Medicare

3. Medigap

4. Medicaid

5. Children's Health Insurance Program (CHIP)

6. Military related health care: TRICARE (CHAMPUS) / VA health care / CHAMPVA

7. Indian Health Service

8. State-sponsored health plan

9. Other government program

10. No coverage of any type

11. Don’t know

12. Prefer not to answer

Usual source of care

1. Is there a place that you usually go if you are sick and need health care?

[Source: National Health Interview Survey]

1. Yes

2. No

3. Don’t know

4. Prefer not to answer

2. [IF YES] What kind of place?

[Source: National Health Interview Survey]

1. A doctor's office or health center

2. An urgent care center

3. A clinic in a drug store or grocery store

4. A hospital emergency room

5. A VA Medical Center or VA outpatient clinic

6. Some other place?

7. Don’t know

8. Prefer not to answer

Health care use

1. During the past 12 months, have you been hospitalized overnight?

[Source: National Health Interview Survey]

1. Yes

2. No

3. Don’t know

4. Prefer not to answer

Preventative Medicine

1. About how long has it been since you last saw a doctor or other health professional for a wellness visit, physical, or general-purpose check-up?

[Source: National Health Interview Survey]

1. Within the past year (any time less than 12 months ago)

2. Within the last 2 years (1 year but less than 2 years ago

3. Within the last 3 years (2 years but less than 3 years ago)

4. Within the last 5 years (5 years but less than 5 years ago)

5. Within the last 10 years (5 years but less than 10 years)

6. 10 or more years ago

7. Don't know

8. Prefer not to answer

2. About how long has it been since you last had a dental examination or cleaning?

[Source: National Health Interview Survey]

1. Within the past year (any time less than 12 months ago)

2. Within the last 2 years (1 year but less than 2 years ago

3. Within the last 3 years (2 years but less than 3 years ago)

4. Within the last 5 years (5 years but less than 5 years ago)

5. Within the last 10 years (5 years but less than 10 years)

6. 10 or more years ago

7. Don't know

8. Prefer not to answer

3. During the past 12 months, have you DELAYED getting medical care because of the cost?

[Source: National Health Interview Survey]

1. Yes

2. No

3. Don’t know

4. Prefer not to answer

4. During the past 12 months, was there any time when you needed medical care, but DID NOT GET IT because of the cost?

[Source: National Health Interview Survey]

1. Yes

2. No

3. Don’t know

4. Prefer not to answer

5. There are many other reasons people delay or do not get medical care. During the past 12 months, did you delay or not get medical care for any of the following reasons

[Source: National Health Interview Survey]

Reason	Yes	No	Don’t know	Prefer not to answer
a...Because an appointment wasn't available when you needed it?
b…Because you couldn't get to the doctor's office or clinic when it was open?
c…Because you had difficulty finding a doctor, clinic, or hospital that would accept your health insurance?
d…Because it takes too long to get to the doctor's office or clinic from your house or work?
e…Because you were too busy with work or other commitments to take the time?
f...Because you didn't have transportation

SUBSTANCE USE

Now I would like to ask you some questions about tobacco and alcohol. We are asking these questions of everyone in the study. Remember that the information you provide will be kept private and your name will never be linked to your responses in reports. [if needed: Some people may find the next few questions personal. Please remember you can choose not to answer any question.]

Tobacco

These next set of questions are about cigarette smoking.

1. Have you smoke at least 100 cigarettes in your ENTIRE LIFE?

[Source: National Health Interview Survey]

1. Yes

2. No

3. Don’t know

4. Prefer not to answer

2. [1=A] Do you NOW smoke cigarettes every day, some days, or not at all?

[Source: National Health Interview Survey]

1. Every day

2. Some days

3. Not at all

4. Don’t know

5. Prefer not to answer

3. Do you currently use chewing tobacco, snuff, or snus every day, some days, or not at all? [Read if necessary: Snus [pronounced “snoos”] (Swedish for snuff) is a moist smokeless tobacco usually sold in small pouches that are placed under the lip against the gum.)

[Source: National Health Interview Survey]

1. Every day

2. Some days

3. Not at all

4. Don’t know

5. Prefer not to answer

4. Do you currently use e-cigarettes or other electronic vaping products every day, some days, or not at all? [Read if necessary: Electronic cigarettes (e-cigarettes) and other electronic vaping products include electronic hookahs (e-hookahs), vape pens, e-cigars, and others. These products are battery-powered and usually contain nicotine and flavors such as fruit, mint, or candy. Brands you may have heard of are JUUL, NJOY, or blu. Interviewer note: These questions concern electronic vaping products for nicotine use. The use of electronic vaping products for marijuana use is not included in these questions.]

[Source: National Health Interview Survey]

1. Every day

2. Some days

3. Not at all

4. Don’t know

5. Prefer not to answer

Binge-drinking

This next question is about drinking alcohol.

1. Over the past 2 weeks, how many occasions have you had [5 (male)/4 (female)] or more drinks in a row?

[Source: National Health Interview Survey]

1. None

2. Once

3. Twice

4. 2 to 5 times

5. 6 to 9 times

6. 10 or more times

7. Don’t know

8. Prefer not to answer

HEALTH CONDITIONS

The next few questions are about your health and health conditions that you may have. Remember, we will keep your responses confidential. [if needed: if you feel that these questions are too personal, you can choose not to answer them.]

Physical health

1. Have you EVER been told by a doctor or other health professional that you had...Hypertension, also called high blood pressure?

[Source: National Health Interview Survey]

1. Yes

2. No

3. Don’t know

4. Prefer not to answer

2. [IF 1=A] During the past 12 months, have you had hypertension or high blood pressure?

[Source: National Health Interview Survey]

1. Yes

2. No

3. Don’t know

4. Prefer not to answer

3. [IF 2=A] Are you now taking prescribed medicine for your high blood pressure?

[Source: National Health Interview Survey]

1. Yes

2. No

3. Don’t know

4. Prefer not to answer

4. Have you ever been told by a doctor or other health professional that you had asthma?

[Source: National Health Interview Survey]

1. Yes

2. No

3. Don’t know

4. Prefer not to answer

5. [IF 4=A] Do you still have asthma?

[Source: National Health Interview Survey]

1. Yes

2. No

3. Don’t know

4. Prefer not to answer

6. [IF 5=A] During the past 12 months, have you had an episode of asthma or an asthma attack?

[Source: National Health Interview Survey]

1. Yes

2. No

3. Don’t know

4. Prefer not to answer

7. [IF 6=A] During the past 12 months, how many episodes of asthma or asthma attacks did you have?

[Source: National Health Interview Survey]

1. ENTER NUMBER OF ASTHMA ATTACKS

2. Don’t know

3. Prefer not to answer

8. [IF 5=A] During the past 12 months, have you had to visit an emergency room or urgent care center because of asthma?

[Source: National Health Interview Survey]

1. Yes

2. No

3. Don’t know

4. Prefer not to answer

9. Has a doctor or other health professional EVER told you that you had prediabetes or borderline diabetes?

[Source: National Health Interview Survey]

1. Yes

2. No

3. Don’t know

4. Prefer not to answer

10. [skip if male] Has a doctor or other health professional EVER told you that you had gestational diabetes, a type of diabetes that occurs ONLY during pregnancy?

[Source: National Health Interview Survey]

1. Yes

2. No

3. Don’t know

4. Prefer not to answer

11. Has a doctor or other health professional EVER told you that you had diabetes?

[Source: National Health Interview Survey]

1. Yes

2. No

3. Don’t know

4. Prefer not to answer

12. [IF 9A=A, 10=A, OR 11=A] How old were you when a doctor or other health professional FIRST told you that you had diabetes?

[Source: National Health Interview Survey]

1. [ENTER AGE]

2. Don’t know

3. Prefer not to answer

13. [IF 9=A OR IF 10=A OR 11=A] Are you NOW taking diabetic pills to lower your blood sugar? These are sometimes called oral agents or oral hypoglycemic agents.

[Source: National Health Interview Survey]

1. Yes

2. No

3. Don’t know

4. Prefer not to answer

14. [IF 9=A OR IF 10=A OR 11=A] Insulin can be taken by shot or pump. Are you NOW taking insulin?

[Source: National Health Interview Survey]

1. Yes

2. No

3. Don’t know

4. Prefer not to answer

15. [IF 9=A OR IF 10=A OR 11=A] According to your doctor or other health professional, what type of diabetes do you have? Is it type 1, type 2, or some other type? If you don't remember or weren't told, that's OK.

[Source: National Health Interview Survey]

1. Type-1

2. Type-2

3. Some other type

4. Don’t know

5. Prefer not to answer

Health Questionnaire, EQ5D

Now I will read some statements. Please tell me which one best describes your health TODAY.

[Source: EQL 5D-5L; https://euroqol.org/eq-5d-instruments/sample-demo/]

Heading	Health TODAY
Mobility Q1	I have no problems in walking about I have slight problems in walking about I have moderate problems in walking about I have severe problems in walking about I am unable to walk about Don’t know Prefer not to answer
Self-care Q2	I have no problem washing and dressing myself I have slight problems washing or dressing myself I have severe problems washing or dressing myself I am unable to wash or dress myself Don’t know Prefer not to answer
Usual activities (e.g., work, study, housework, family or leisure) Q3	I have no problems doing my usual activities I have slight problems doing my usual activities I have moderate problems doing my usual activities I have severe problems doing my usual activities I am unable to do my usual activities Don’t know Prefer not to answer
Pain/discomfort Q4	I have no pain or discomfort I have slight pain or discomfort I have moderate pain or discomfort I have severe pain or discomfort I have extreme pain or discomfort Don’t know Prefer not to answer
Anxiety/depression Q5	I am not anxious or depressed I am slightly anxious or depressed I am moderately anxious or depressed I am severely anxious or depressed I am extremely anxious or depressed Don’t know Prefer not to answer

6. We would like to know how good or bad your health is TODAY. On a scale of 0 to 100 where 100 means the best health you can imagine and 0 means the worst health you can imagine, how is your health TODAY?

___RANGE 0-100

___Don’t know

___Prefer not to answer

MENTAL HEALTH

The Patient Health Questionnaire

The next few questions are about your mental health. [if needed: if you feel that these questions are too personal, you can choose not to answer them.] Thinking now about the last 2 weeks…

Over the last 2 weeks, how often have you been bothered by any of the following problems?

1. Little interest or pleasure in doing things.

[Source: Kroenke, K., Spitzer, R., & Williams, J. (2001). The PHQ-9: validity of a brief depression severity measure. Journal of General Internal Medicine.]

1. Not at all

2. Several days

3. More than half the days

4. Nearly every day

5. Don’t know

6. Prefer not to answer

2. Feeling down, depressed, or hopeless.

[Source: Kroenke, K., Spitzer, R., & Williams, J. (2001). The PHQ-9: validity of a brief depression severity measure. Journal of General Internal Medicine.]

1. Not at all

2. Several days

3. More than half the days

4. Nearly every day

5. Don’t know

6. Prefer not to answer

3. Trouble falling or staying asleep or sleeping too much.

[Source: Kroenke, K., Spitzer, R., & Williams, J. (2001). The PHQ-9: validity of a brief depression severity measure. Journal of General Internal Medicine.]

1. Not at all

2. Several days

3. More than half the days

4. Nearly every day

5. Don’t know

6. Prefer not to answer

4. Feeling tired or having little energy.

[Source: Kroenke, K., Spitzer, R., & Williams, J. (2001). The PHQ-9: validity of a brief depression severity measure. Journal of General Internal Medicine.]

1. Not at all

2. Several days

3. More than half the days

4. Nearly every day

5. Don’t know

6. Prefer not to answer

5. Poor appetite or overeating.

[Source: Kroenke, K., Spitzer, R., & Williams, J. (2001). The PHQ-9: validity of a brief depression severity measure. Journal of General Internal Medicine.]

1. Not at all

2. Several days

3. More than half the days

4. Nearly every day

5. Don’t know

6. Prefer not to answer

6. Feeling bad about yourself – or that you are a failure or have let yourself or your family down.

[Source: Kroenke, K., Spitzer, R., & Williams, J. (2001). The PHQ-9: validity of a brief depression severity measure. Journal of General Internal Medicine.]

1. Not at all

2. Several days

3. More than half the days

4. Nearly every day

5. Don’t know

6. Prefer not to answer

7. Trouble concentrating on things, such as reading the newspaper or watching television.

[Source: Kroenke, K., Spitzer, R., & Williams, J. (2001). The PHQ-9: validity of a brief depression severity measure. Journal of General Internal Medicine.]

1. Not at all

2. Several days

3. More than half the days

4. Nearly every day

5. Don’t know

6. Prefer not to answer

8. Moving or speaking so slowly that other people could have noticed? Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual.

[Source: Kroenke, K., Spitzer, R., & Williams, J. (2001). The PHQ-9: validity of a brief depression severity measure. Journal of General Internal Medicine.]

1. Not at all

2. Several days

3. More than half the days

4. Nearly every day

5. Don’t know

6. Prefer not to answer

Generalized Anxiety Disorder 2-item

Over the last 2 weeks, how often have you been bothered by the following problems?

1. Feeling nervous, anxious, or on edge.

[Source: Generalized Anxiety Disorder 2-item (GAD-2); https://www.hiv.uw.edu/page/mental-health-screening/gad-2]

1. Not at all

2. Several days

3. More than half the days

4. Nearly every day

5. Don’t know

6. Prefer not to answer
   
   

2. Not being able to stop or control worrying.

[Source: Generalized Anxiety Disorder 2-item (GAD-2); https://www.hiv.uw.edu/page/mental-health-screening/gad-2]

1. Not at all

2. Several days

3. More than half the days

4. Nearly every day

5. Don’t know

6. Prefer not to answer

Mental Health Services

1. Has a doctor or other health professional ever diagnosed you with one of the following emotional or mental health conditions? Check all that apply.

[Source: Local survey by Sabriya Linton on Baltimore HOPE VI redevelopment]

1. Anxiety or panic disorder (Yes/No/Don’t know/Refuse to Answer)

2. Depression (Yes/No/Don’t know/Refuse to Answer)

3. Manic Depression or bipolar disorder (Yes/No/Don’t know/Refuse to Answer)

4. Schizophrenia/ Schizoaffective disorder (Yes/No/Don’t know/Refuse to Answer)

5. Other emotional or mental health condition (Specify if yes:_______)

   1. Yes

   2. No

   3. Don’t know

   4. Prefer not to answer

2. In the past 12 months, have you ever received treatment from a doctor or other health professional for an emotional or mental health condition? (7 = Don't Know; 8 = Refuse to Answer)

[Source: Local survey by Sabriya Linton on Baltimore HOPE VI redevelopment]

1. Yes

2. No

3. Don’t know

4. Prefer not to answer

SOCIAL SERVICE PARTICIPATION

Now I would like to ask you about different sources of income or assistance you or people in your family living with you now may receive. Your responses to these questions will not affect your family’s eligibility for housing assistance or other types of assistance. By family, I mean the people you told us about at enrollment who live with you now and who would move with you if you moved. [if needed: if you feel that these questions are too personal, you can choose not to answer them.]

1. At any time in the last 12 months did any family members living here receive SNAP or food stamp benefits?

[Source: National Health Interview Survey]

1. Yes

2. No

3. Don’t know

4. Prefer not to answer

2. Did any family members living here receive SNAP or food stamp benefits in the LAST 30 days?

[Source: National Health Interview Survey]

1. Yes

2. No

3. Don’t know

4. Prefer not to answer

3. At any time in the last 12 months did any family members living here receive benefits from the WIC program, that is, the Women, Infants, and Children program?

[Source: National Health Interview Survey]

1. Yes

2. No

3. Don’t know

4. Prefer not to answer

4. At any time in the last 12 months, did any child in your family receive free or reduced-cost breakfasts or lunches at school through the National School Lunch Program?

[Source: National Health Interview Survey]

1. Yes

2. No

3. Don’t know

4. Prefer not to answer

CHILDHOOD SES

1. Thinking about your main caregiver while you were growing up, what was the highest grade in school that he or she completed? If you had more than one caregiver, think about the one who you spent the most time with growing up.

[IF NEEDED: Your responses are confidential and will not be shared. You may skip any question you’re not comfortable answering]

[Source: Sarah Szanton & Boeun Kim; adapted from National Health and Aging Trends study & Health Retirement Study]

1. Less than high school

2. High school diploma

3. GED certificate

4. Some vocational/technical/business courses

5. Vocational/technical/business certificate or diploma

6. Some college

7. Associate’s or two-year college degree

8. Bachelor’s or four-year college degree or higher

9. Don’t know

10. Prefer not to answer

2. Please record the address you lived at when you were a child. If you lived at many different addresses, please choose the one that you most identify with as your home when you were growing up.

[IF NEEDED: Your responses are confidential and will not be shared. You may skip any question you’re not comfortable answering]

[Source: Sarah Szanton & Boeun Kim; adapted from National Health and Aging Trends study & Health Retirement Study]

1. Street number, name, city, state, zip

2. Don’t Know

3. Prefer not to answer

DISCRIMINATION AND SAFETY

The next few questions are about how you are treated in your everyday life. We hope to better understand more about everyone in the study’s personal experiences. [if needed: if you feel that these questions are too personal, you can choose not to answer them.]

Everyday Discrimination Scale – Short Form

1. In your day-to-day life how often have any of the following things happened to you? Almost every day, at least once a week, a few times a month, a few times a year, less than once a year, or never? [These are the response options for each question]

[Source: Everyday Discrimination Scale, Short Form; https://scholar.harvard.edu/davidrwilliams/node/32397]

1. You are treated with less courtesy or respect than other people.

2. You receive poorer service than other people at restaurants or stores.

3. People act as if they think you are not smart.

4. People act as if they are afraid of you.

5. You are threatened or harassed.

   1. Almost every day

   2. At least once a week

   3. A few times a month

   4. A few times a year

   5. Less than once a year

   6. Never

   7. Don’t know

   8. Prefer not to answer

2. [IF RESPONSE TO AT LEAST ONE QUESTION ABOVE IS “A FEW TIMES A YEAR” OR MORE] What do you think is the main reason for this experience? [SELECT ALL THAT APPLY]

[Source: Everyday Discrimination Scale, Short Form; https://scholar.harvard.edu/davidrwilliams/node/32397]

1. Your Ancestry or National Origins   

2. Your Gender   

3. Your Race   

4. Your Age   

5. Your Religion

6. Your Height   

7. Your Weight

8. Some other Aspect of Your Physical Appearance

9. Your Sexual Orientation

10. Your Education or Income Level   

11. Don’t know

12. Prefer not to answer

Police Practices Inventory

Thinking again about your neighborhood…

1. How much of a police presence is in your neighborhood?

[Source: RAND Corporation’s PHRESH Survey (Pittsburgh Hill/Homewood Research On Neighborhood Change and Health]

1. Not enough

2. Enough

3. Too much

4. Don’t know

5. Prefer not to answer

Perceived stress scale

Changing topics…

1. In the last month, how often have you felt that you were unable to control the important things in your life?

[Source: Perceived Stress Scale (PSS-4); Wartig, S., Forshaw, M., … & White, A. (2013). New, normative English-sample data for the Short Form Perceived Stress Scale (PSS-4). Journal of Health Psychology.]

1. Never

2. Almost never

3. Sometimes

4. Fairly often

5. Very often

6. Don’t know

7. Prefer not to answer

2. In the last month, how often have you felt confident about your ability to handle your personal problems?

[Source: Perceived Stress Scale (PSS-4); Wartig, S., Forshaw, M., … & White, A. (2013). New, normative English-sample data for the Short Form Perceived Stress Scale (PSS-4). Journal of Health Psychology.]

1. Never

2. Almost never

3. Sometimes

4. Fairly often

5. Very often

6. Don’t know

7. Prefer not to answer

3. In the last month, how often have you felt that things were going your way?

[Source: Perceived Stress Scale (PSS-4); Wartig, S., Forshaw, M., … & White, A. (2013). New, normative English-sample data for the Short Form Perceived Stress Scale (PSS-4). Journal of Health Psychology.]

1. Never

2. Almost never

3. Sometimes

4. Fairly often

5. Very often

6. Don’t know

7. Prefer not to answer

4. In the last month, how often have you felt difficulties were piling up so high that you could not overcome them?

[Source: Perceived Stress Scale (PSS-4); Wartig, S., Forshaw, M., … & White, A. (2013). New, normative English-sample data for the Short Form Perceived Stress Scale (PSS-4). Journal of Health Psychology.]

1. Never

2. Almost never

3. Sometimes

4. Fairly often

5. Very often

6. Don’t know

7. Prefer not to answer

Perceived Constraints of Sense of Control

Please rate how you agree with the following statements. [READ ITEM] Would you say…[READ ANSWER CHOICES]

[Source: Perceived Constraints on Sense of Control; https://psycnet.apa.org/record/1998-00299-016]

	Strongly agree	Agree	Neither agree nor disagree	Disagree	Strongly disagree	Don’t know	Prefer not to answer
a. Other people determine most of what I can and cannot do
b. There is little I can do to change many of the important things in my life
c. I often feel helpless in dealing with the problems of life
d. What happens in my life is often beyond my control
e. There are many things that interfere with what I want to do

NEIGHBORHOOD SOCIAL ENVIRONMENT

The next few questions ask about your neighborhood and how often neighbors interact with each other. [if needed: if you feel that these questions are too personal, you can choose not to answer them.]

Collective efficacy scale

Could your neighbors be counted on to intervene if…

1. Children were skipping school and hanging out on a street corner.

[Source: Collective Efficacy Short Form – 10]

1. Very likely

2. Likely

3. Neither likely nor unlikely

4. Unlikely

5. Very unlikely

6. Don’t know

7. Prefer not to answer

2. Children were spray-painting graffiti on a local building

[Source: Collective Efficacy Short Form – 10]

1. Very likely

2. Likely

3. Neither likely nor unlikely

4. Unlikely

5. Very unlikely

6. Don’t know

7. Prefer not to answer
   
   

1. Children were showing disrespect to an adult

[Source: Collective Efficacy Short Form – 10]

1. Very likely

2. Likely

3. Neither likely nor unlikely

4. Unlikely

5. Very unlikely

6. Don’t know

7. Prefer not to answer

4. A fight broke out in front of their house

[Source: Collective Efficacy Short Form – 10]

1. Very likely

2. Likely

3. Neither likely nor unlikely

4. Unlikely

5. Very unlikely

6. Don’t know

7. Prefer not to answer

5. The fire station closest to their home was threatened with budget cuts

[Source: Collective Efficacy Short Form – 10]

1. Very likely

2. Likely

3. Neither likely nor unlikely

4. Unlikely

5. Very unlikely

6. Don’t know

7. Prefer not to answer

Please rate how much you agree with the following statements

6. People around here are willing to help their neighbors

[Source: Collective Efficacy Short Form – 10]

1. Strongly agree

2. Agree

3. Neither agree nor disagree

4. Disagree

5. Strongly disagree

6. Don’t know

7. Prefer not to answer

7. This is a close-knit neighborhood

[Source: Collective Efficacy Short Form – 10]

1. Strongly agree

2. Agree

3. Neither agree nor disagree

4. Disagree

5. Strongly disagree

6. Don’t know

7. Prefer not to answer

8. People in this neighborhood can be trusted

[Source: Collective Efficacy Short Form – 10]

1. Strongly agree

2. Agree

3. Neither agree nor disagree

4. Disagree

5. Strongly disagree

6. Don’t know

7. Prefer not to answer

9. People in this neighborhood generally don’t get along with each other

[Source: Collective Efficacy Short Form – 10]

1. Strongly agree

2. Agree

3. Neither agree nor disagree

4. Disagree

5. Strongly disagree

6. Don’t know

7. Prefer not to answer

10. People in this neighborhood do not share the same values

[Source: Collective Efficacy Short Form – 10]

1. Strongly agree

2. Agree

3. Neither agree nor disagree

4. Disagree

5. Strongly disagree

6. Don’t know

7. Prefer not to answer

Neighbors

Questions about neighborhood social support

Please tell me if you have access to the following in your neighborhood

[Source: Mobilizing Social Capital; https://www.tandfonline.com/doi/abs/10.1080/02673037.2016.1140724?journalCode=chos20]

1. A car to borrow, if needed

1. Yes

2. No

3. Don’t know

4. Prefer not to answer

2. Someone to give you a ride, if needed

   1. Yes

   2. No

   3. Don’t know

   4. Prefer not to answer

3. Babysitting for children

   1. Yes

   2. No

   3. Don't know

   4. Prefer not to answer

4. Assistance with a computer

   1. Yes

   2. No

   3. Don’t know

   4. Prefer not to answer

5. Residents who are active in community organizations

   1. Yes

   2. No

   3. Don’t know

   4. Prefer not to answer

6. Advice about job opportunities

   1. Yes

   2. No

   3. Don’t know

   4. Prefer not to answer

7. Assistance with food or medicine when ill

   1. Yes

   2. No

   3. Don’t know

   4. Prefer not to answer

8. Someone to discuss personal matters with

   1. Yes

   2. No

   3. Don’t know

   4. Prefer not to answer

9. Someone who could lend $100 if needed

   1. Yes

   2. No

   3. Don’t know

   4. Prefer not to answer

10. Someone to have a meal with

    1. Yes

    2. No

    3. Don't know

    4. Prefer not to answer

BRIDGING SOCIAL CAPITAL

Now I am going to ask you about your friendships. Please let me know if the following describe nearly all, most, some, a few, or none of your friendships.

[Source: New question, adapted from prior survey, Schwartz (2014); onhttps://www.sciencedirect.com/science/article/pii/S0277953613005479?via%3Dihub]

1. My friends live in the neighborhood.

1. Nearly all

2. Most

3. Some

4. A few

5. None

6. Don’t know

7. Prefer not to answer

2. My friends have graduated from college.

   1. Nearly all

   2. Most

   3. Some

   4. A few

   5. None

   6. Don’t know

   7. Prefer not to answer

3. My friends are different races or ethnicities than me.

   1. Nearly all

   2. Most

   3. Some

   4. A few

   5. None

   6. Don’t know

   7. Prefer not to answer

PREDICTABILITY

1. Sometimes things happen that completely throw your plans off course or mess things up. How likely or unlikely do you think something like that will happen to you or your family in the next 12 months?

   1. Very likely

   2. Somewhat likely

   3. Neither likely nor unlikely

   4. Somewhat unlikely

   5. Very unlikely

   6. Don’t know

   7. Prefer not to answer

PET OWNERSHIP

1. Does your household currently have a dog?

   1. Yes

   2. No

   3. Don’t know

   4. Prefer not to answer

ONLY AT FOLLOW-UP

We're almost done, I just have a few final questions to ask.

1. Where do you currently live?

1. In an apartment, home, or room that you rent or sublet

2. In a home or apartment that you own

3. In an apartment, home, or room that friends or extended family rents where you contribute to part of the rent

4. With friends or family, where you do not pay any rent

5. Homeless or in a group shelter

6. Other housing arrangement:

7. Don't know

8. Prefer not to answer

2. Do you agree or disagree with this statement: “The size or physical condition of my home makes it harder to be the parent I want to be for my children”?

1. Strongly agree

2. Agree

3. Agree somewhat

4. Disagree

5. Strongly disagree

6. Don’t know

7. Prefer not to answer

3. Which of the following statements best describes how satisfied you are with your current neighborhood?

1. Very satisfied

2. Somewhat satisfied

3. In the middle

4. Somewhat dissatisfied

5. Very dissatisfied

6. Don't know

7. Prefer not to answer

The next questions are about specific features of your current neighborhood.

4. How satisfied are you with …

1. The friendliness of neighbors in your neighborhood?

2. The racial and ethnic mix of your neighborhood?

3. How near your neighborhood is to your job?

4. Your neighborhood’s access to public transportation?

5. The appearance of your neighborhood (cleanliness, lack of graffiti)?

6. The amenities of your neighborhood (parks, access to shops, places of worship, schools, dining)?

7. How near your neighborhood is to your family and friends?

8. The size of your home? [Skip if Q1 = 5]

9. The quality of your home? [Skip if Q1 = 5]

1. Very Satisfied

2. Satisfied

3. Neither satisfied nor dissatisfied

4. Dissatisfied

5. Very Dissatisfied

6. Not applicable (for item c, only)

7. Don't know

8. Prefer not to answer

5. Do you agree or disagree with this statement: “The neighborhood conditions where I live make it harder to be the parent I want to be for my children”?

1. Strongly agree

2. Agree

3. Agree somewhat

4. Disagree

5. Strongly disagree

6. Don't know

7. Prefer not to answer

6. Where you live now, how much of a problem are rats, mice, cockroaches or other vermin?

1. Big problem

2. Small problem

3. No problem at all

4. Don't know

5. Prefer not to answer

7. How safe are the streets near your home during the day?

1. Very safe

2. Safe

3. Somewhat unsafe

4. Unsafe

5. Very unsafe

6. Don't know

7. Prefer not to answer

8. How safe are the streets near your home at night?

1. Very safe

2. Safe

3. Somewhat unsafe

4. Unsafe

5. Very unsafe

6. Don't know

7. Prefer not to answer

9. How often are you worried about gun violence in your neighborhood?

1. None of the time

2. A little of the time

3. Some of the time

4. Most of the time

5. All of the time

6. Don't know

7. Prefer not to answer

10. Please tell me if any of the following things have happened to you or anyone who lives with you in the past 6 months.

1. Was anyone's purse, wallet, or jewelry snatched from them?

2. Was anyone threatened with a knife or gun?

3. Was anyone beaten or assaulted?

4. Was anyone stabbed or shot?

5. Did anyone try to break into your home?

1. Yes

2. No

3. Don't know

4. Prefer not to answer

11. Which of the following are located in or near your current neighborhood? (Check all that apply) [Respondent needs to check either Yes, No, or Not Applicable for items A– K., unless L. Prefer not to answer is checked.]

1. One or more of my children’s childcare providers

2. One or more of my children’s after-school activities

3. My job or the job of another person in the household

4. Other family members who do not live with me

5. Close friends who do not live with me

6. My church or place of worship

7. Other community groups I or my family is involved with

8. My primary care doctor

9. The primary care doctor of one or more of my children

10. Other medical services that I or others in the household use regularly

11. Other important services (specify)

12. Prefer not to answer

12. In general, how do your household’s finances usually work out at the end of the month?

1. There is some money left over

2. There is just enough to make ends meet

3. There is not enough money to make ends meet

4. Don't know

5. Prefer not to answer

13. Are you currently working for pay?

1. Yes

2. No (Skip to Q15)

3. Don’t know (Skip to Q15)

4. Prefer not to answer (Skip to Q15)

14. About how many hours per week do you usually work? (Round the time to the nearest whole hour. For example, if you work 22.5 hours per week, please record 23 hours.)

    1. ___Hours

    2. Don’t know

    3. Prefer not to answer

15. Taken all together, how would you say things are these days; would you say that you are very happy, pretty happy, or not too happy?

1. Very happy

2. Pretty happy

3. Not too happy

4. Don't know

5. Prefer not to answer

16. In general, how would you rate your overall health now? Is it…

1. Excellent

2. Very good

3. Good

4. Fair

5. Poor

6. Don't know

7. Prefer not to answer

17. [skip if male] Are you currently pregnant?

    1. yes

    2. no

    3. not applicable

    4. Don't know

    5. prefer not to answer

That is all the questions we have at this time. Thank you very much for taking the time to talk with us today.