Attachment 11 - Theory-based Drivers of Behavior

THEORY-BASED DRIVERS OF BEHAVIOR

Form Approved

OMB No. 0920-0572

Expiration Date: XX-XX-XXXX

1. Theory-based Drivers of Behavior

The following questions are theory-based drivers of behavior that communications can impact. These can be used for assessing how communications influence people’s behaviors and can be used in both open- and closed-ended questions (surveys, focus groups, etc.)

KNOWLEDGE

1. How much do you currently know about [TOPIC]? Please use the scale of zero to 100, where zero means knowing nothing and 100 means knowing everything you could possibly know about this topic.

2. Have you, yourself, become sick or do you know anyone who has become sick due to [TOPIC]?

• Yes, I have been diagnosed with [TOPIC] by a healthcare provider

• Yes, I know someone who has been diagnosed with [TOPIC] by a healthcare provider

• Possibly – I have had the signs and symptoms of [TOPIC], but was not diagnosed with [TOPIC]

• Possibly – I know someone who has had the signs and symptoms of [TOPIC], but was not diagnosed with [TOPIC]

• No, I do not know anyone who has had [TOPIC] or its symptoms

2. What are the signs and symptoms that a person is infected with [TOPIC]? (Select all that apply.)

• [INSERT SIGNS AND SYMPTOMS AS NEEDED]

THREATS

2. According to the Centers for Disease Control and Prevention, who is most at risk of becoming infected with [TOPIC]?

• [INSERT POPULATIONS AS NEEDED]

2. According to the Centers for Disease Control and Prevention, who should [ACTION] when [CONTEXT/SETTING]?

• [INSERT POPULATIONS AS NEEDED]

2. When you think about the possible health risk posed to [you/your loved ones/your community] from [TOPIC], how much worry do you feel? Please use the scale of zero to 100, where zero means you have “none of this feeling” and 100 means you have “a lot of this feeling.”

2. How likely do you think it is that [you/your loved ones/your community] will become ill from [TOPIC]? Please use a scale from zero to 100, where zero means that you would have absolutely no chance whatsoever of becoming ill, and 100 means that you are certain to.

SEVERITY

2. If [you/your loved ones/your community] were to become ill from [TOPIC], how serious do you think this illness would be? Please use a scale of zero to 100, where zero means not serious at all and 100 means it would be as serious as it can possibly be.

2. If you started experiencing symptoms of [TOPIC] ([INSERT SYMPTOMS]) and thought you may have been exposed, what would you do first?

• Go to the emergency room or see a doctor

• Call the health department

• Seek alternative medical treatment

• Wait to see if symptoms go away

• [INSERT ACTIONS AS NEEDED]

• None of these

BEHAVIORS, BENEFITS, AND EFFICACY

2. What do you think are the most important things people can do to prevent becoming infected with [TOPIC] or protect themselves from getting [TOPIC]?

2. Which of the following actions have you heard are the most important things people can do to prevent from getting infected with [TOPIC]?

• [INSERT ACTIONS AS NEEDED]

2. How often have you seen, heard, or read about any of the following actions as being important for preventing [TOPIC]: ADD LIST OF BEHAVIORS

• [INSERT FREQUENCIES AS NEEDED]

2. In the past [TIMEFRAME], when you have gone [to INSERT setting or context], how often did you [INSERT behavior]?

• [INSERT FREQUENCIES AS NEEDED]

2. In the past [TIMEFRAME], when you have gone [to INSERT setting or context], how often did you see others [INSERT behavior]?

• [INSERT FREQUENCIES AS NEEDED]

2. In the past [TIMEFRAME], when you [ACTIVITY/BEHAVIOR], how often did you…

For example: Wear a cloth face covering that covered your face and mouth

	Never	Rarely	Sometimes	Often	Always	Not sure
[INSERT ACTION A]	1	2	3	4	5	9
[INSERT ACTION B]	1	2	3	4	5	9
[INSERT ACTION ETC]	1	2	3	4	5	9

2. How personally important is it to you…

For example: To protect others from coronavirus

	Not at all important	A little important	Somewhat important	Very important	Extremely important	Not sure
[INSERT STATEMENT A]	1	2	3	4	5	9
[INSERT STATEMENT B]	1	2	3	4	5	9
[INSERT STATEMENT ETC]	1	2	3	4	5	9

2. How much information would you need to adequately deal with the possible risk from [TOPIC] in your own life? Please use the scale of zero to 100, where zero means you need no more information and 100 means you need a lot more information.

2. How much do you trust the information about [TOPIC] that comes from each of the following sources?

For example: The Centers for Disease Control (CDC)

	Not at all	A little	Somewhat	A lot	Completely	Not sure
[INSERT SOURCE A]	1	2	3	4	5	9
[INSERT SOURCE B]	1	2	3	4	5	9
[INSERT SOURCE ETC]	1	2	3	4	5	9

2. Which one of the following best describes your access to [PROTECTIVE ITEM]?

• I have [PROTECTIVE ITEM]

• I do not currently have [PROTECTIVE ITEM]

• [INSERT ADDITIONAL OPTIONS RELATED TO ACCESS TO PROTECTIVE ITEMS]

• I do not plan to make, purchase, or obtain a [PROTECTIVE ITEM]

BATTERY ALIGNED WITH BEHAVIORAL CONSTRUCTS

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

	Strongly disagree				Strongly agree	Not sure
It is important for [PERSON] to [BEHAVIOR IN CONTEXT]	1	2	3	4	5	9
I believe I should [BEHAVIOR IN CONTEXT]	1	2	3	4	5	9
I intend to [BEHAVIOR IN CONTEXT]	1	2	3	4	5	9
[BEHAVIOR IN CONTEXT] is easy for me.	1	2	3	4	5	9
I am able to [BEHAVIOR IN CONTEXT]	1	2	3	4	5	9
I am confident that I can [BEHAVIOR IN CONTEXT] to prevent the spread of [TOPIC]	1	2	3	4	5	9
For me personally, it would not be a big deal if I became infected with [TOPIC]	1	2	3	4	5	9
I’m worried I would become seriously ill if I became infected with [TOPIC]	1	2	3	4	5	9
People who are important to me want me to [BEHAVIOR IN CONTEXT]	1	2	3	4	5	9
People who are important to me believe that I should [BEHAVIOR IN CONTEXT]	1	2	3	4	5	9
Most people are [BEHAVIOR IN CONTEXT]	1	2	3	4	5	9
I think it is likely that I will become infected with [TOPIC]	1	2	3	4	5	9
I would [EXPECTED OUTCOME] for others from [TOPIC] if I [BEHAVIOR IN CONTEXT]	1	2	3	4	5	9
I would [EXPECTED OUTCOME] from [TOPIC] if I [BEHAVIOR IN CONTEXT]	1	2	3	4	5	9
Everyone [DOING BEHAVIOR IN CONTEXT] would [EXPECTED OUTCOME]	1	2	3	4	5	9
[BEHAVIOR IN CONTEXT] would [EXPECTED OUTCOME]	1	2	3	4	5	9
I can help stop the [TOPIC] outbreak in my community if I [BEHAVIOR IN CONTEXT]	1	2	3	4	5	9
[BARRIER] limits my ability or likelihood to [BEHAVIOR IN CONTEXT]	1	2	3	4	5	9
For me personally, it would not be a big deal if I became infected with [TOPIC]	1	2	3	4	5	9
I don’t feel the need to do anything to protect myself or my family from [TOPIC]	1	2	3	4	5	9
In my life, it would be easy for me to avoid becoming ill from [TOPIC]	1	2	3	4	5	9
[TOPIC] [can/cannot] be spread by [TRANSMISSION TYPE]	1	2	3	4	5	9
Medicines for treating [TOPIC] are safe and effective	1	2	3	4	5	9
Vaccines for [TOPIC] are safe and effective	1	2	3	4	5	9
I would be scared of how other people would react to me if they found out I had a [TOPIC] infection	1	2	3	4	5	9
I would not feel embarrassed if I were to get infected with [TOPIC]	1	2	3	4	5	9