General Population

Attachment E-1

National Survey of U.S. Public’s Awareness of Racial and Ethnic Health Disparities

Questionnaire, General Population

Attachment E-1

Form Approved OMB No. 0990-0335

Exp. Date XX/XX/20XX

NATIONAL SURVEY OF U.S. PUBLIC’S AWARENESS

OF RACIAL AND ETHNIC HEALTH DISPARITIES

General Population Edition

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-0335. The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer.

I’d like to begin by asking you some questions about your health care and health information.

1. At what type of facility do you usually receive your medical care? Is it a doctor’s office, a clinic or health center, an HMO, a hospital emergency room, a hospital outpatient department or some other place? (Select all that apply)

1. Doctor’s office

2. Clinic or health center

3. HMO

4. Hospital emergency room

5. Hospital outpatient department

6. Other (specify: ___________)

8. (Don’t know)

9. (Refused)

________________________________________________________________________

2. How do you typically learn of general medical information? (Select all that

apply)

1. The Internet

2. Newspaper

3. Medical Journals

4. By talking with my doctor

5. Television (news/documentary)

6. Radio

7. Friends/family

8. Other (please explain)_______________________________________________

9. (Don’t’ know)

10. (Refused)

1. YES

2. NO

8. (DON’T KNOW)

9. (REFUSED)

________________________________________________________________________

[NEWQ1] Now I will mention some things that may or may not put people at greater risk of having poor health. For each, please tell me if you think it is a major risk, a minor risk, or not a risk at all. (First) what about…(INSERT ITEMS,RANDOMIZE)?

READ IF NECESSARY: Is this a major risk, a minor risk, or not a risk at all for people having poor health?

[Randomize items:]

a. Being a racial or ethnic minority

b. Being female

c. Being physically disabled

d. Being mentally disabled

e. Being gay, lesbian, bisexual, or transsexual

f. Being overweight or obese

g. Having little or no physical activity or exercise

h. Having limited or no English-speaking ability

i. Having no health insurance

j. Having no or limited education

k. Being unemployed or under-employed

l. Living in poverty or under economic stress

m. Having inadequate or no housing

n. Living with little or no transportation

o. Living in an unsafe neighborhood (e.g., high crime, drug use, vandalism)

p. Living in neighborhoods exposed to physical hazards, such as excessive trash, air or water pollution, and toxic substances

1. MAJOR RISK

2. MINOR RISK

3. NO RISK AT ALL

8. (DON’T KNOW)

9. (REFUSED)

________________________________________________________________________

[NEWQ2] ASK IF RESPONDENT ANSWERS 1 OR 2 FOR ANY ITEM NEWQ1a-p: For people who may be at higher risk than others of having poorer health because of the reasons you just identified, are you aware of any organizations or groups within your community who are working to eliminate such health differences?

1. YES

2. NO

8. (DON’T KNOW)

9. (REFUSED)

________________________________________________________________________

3. In the last year, have you heard or read anything about racial and ethnic disparities in health and health care in America?

1. YES  (IF YES, BRIEFLY DESCRIBE AND/OR PROVIDE EXAMPLES)

2. NO

4. Have you ever heard of any of the following public health campaigns or read any of the following publications?

1. The US Department of Health and Human Services’ Healthy People 2020

2. The Agency for Healthcare Research and Quality’s National Healthcare Disparities Report

3. The Office of Minority Health’s National Partnership for Action

1. Yes

2. No

8. (Don’t know)

9. (Refused)

________________________________________________________________________

5. Thinking about people like yourself, is:

1. being able to afford the cost of health insurance and necessary medical care;

2. having enough doctors and other health providers near where they live;

3. having difficulty getting care because of your race or ethnic background

a major problem, a minor problem or not a problem?

1. Major problem

2. Minor problem

3. Not a problem at all

8. (Don’t know)

9. (Refused)

________________________________________________________________________

For the next few questions, I would like you to think about African Americans in our country today.

6. Do you think the average African American is better off, worse off or just as well off as the average white person in terms of:

a. getting needed health care;

b. infant mortality—that is, a baby’s chance of surviving after birth;

c. life expectancy—that is, how long someone can expect to live?

1. BETTER OFF

2. WORSE OFF

3. JUST AS WELL OFF

8. (DON’T KNOW)

9. (REFUSED)

________________________________________________________________________

7. Do you think the average African American is more likely, just as likely, or less likely to be diagnosed (or to have):

1. Auto Immune Deficiency Disorder (AIDS) or the HIV virus

2. Cancer (including cancer of the stomach, prostate, or bladder)

3. Hypertension

4. Diabetes

as the average white person?

1. MORE LIKELY

2. JUST AS LIKELY

3. LESS LIKELY

8. (DON’T KNOW)

9. (REFUSED)

________________________________________________________________________

8. When going to a doctor or health clinic for health care services, do you think most

African Americans receive the same quality of health care as whites, higher quality of care or lower quality of health care as most whites?

1. SAME QUALITY

2. Higher quality

3. Lower quality

8. (Don’t know)

9. (Refused)

________________________________________________________________________

9. Do you think the average African American is better off, worse off or just as well off as

the average white person in terms of:

1. how healthy they are;

2. getting routine medical care when they need it;

3. getting specialized treatments or surgery when they need it;

4. having health insurance?

1. Better off

2. Worse off

3. Just as well off

8. (Don’t know)

9. (Refused)

________________________________________________________________________

10. How big a problem do you think

1. being able to afford the cost of health insurance and necessary medical care;

2. having enough doctors and other health providers near where they live;

3. having difficulty getting care because of their race or ethnic background;

is for the average African American? Is this a major problem, a minor problem or not a problem at all for the average African American?

1. Major problem

2. Minor problem

3. Not a problem at all

8. (Don’t know)

9. (Refused)

________________________________________________________________________

Now, thinking about Hispanics or Latinos in our country today.

11. Do you think the average Hispanic/Latino is better off, worse off or just as well off as the

average white person in terms of:

1. getting needed health care;

2. infant mortality—that is, a baby’s chance of surviving after birth;

3. life expectancy—that is, how long someone can expect to live?

1. Better off

2. Worse off

3. Just as well off

8. (Don’t know)

9. (Refused)

________________________________________________________________________

12. Do you think the average Hispanic/Latino is more likely, just as likely, or less likely to be

diagnosed (or to have):

1. Auto Immune Deficiency Syndrome (AIDS) or the HIV virus

2. Cancer (including cancer of the stomach and liver)

3. Hypertension

4. Diabetes

as the average white person?

1. More likely

2. Just as likely

3. Less likely

8. (Don’t know)

9. (Refused)

________________________________________________________________________

13. When going to the doctor or health clinic for health care services, do you think most Hispanics/Latinos receive the same quality of health care as whites, higher quality of care or lower quality of health care as most whites?

1. Same quality

2. Higher quality

3. Lower quality

8. (Don’t know)

9. (Refused)

________________________________________________________________________

14. How big a problem do you think:

1. being able to afford the cost of health insurance and necessary medical care;

2. having enough doctors and other health providers near where they live;

3. having difficulty getting care because of their race or ethnic background;

is for the average Hispanic/Latino? Is this a major problem, a minor problem or not a problem at all for the average Hispanic/Latino?

1. Major problem

2. Minor problem

3. Not a problem at all

8. (Don’t know)

9. (Refused)

________________________________________________________________________

15. Do you think the average Hispanic/Latino is better off, worse off or just as well off as the average white person in terms of:

1. how healthy they are;

2. getting routine medical care when they need it;

3. getting specialized treatments or surgery when they need it;

4. having health insurance?

1. Better off

2. Worse off

3. Just as well off

8. (Don’t know)

9. (Refused)

________________________________________________________________________

Now, thinking about Asian Americans/ Pacific Islanders in our country today,

16. Do you think the average Asian American/Pacific Islander is better off, worse off or just as well off as the average white person in terms of:

1. getting needed health care;

2. infant mortality—that is, a baby’s chance of surviving after birth;

3. life expectancy—that is, how long someone can expect to live?

1. Better off

2. Worse off

3. Just as well off

8. (Don’t know)

9. (Refused)

________________________________________________________________________

17. Do you think the average Asian American/Pacific Islander is more likely, just as likely, or less likely to be diagnosed (or to have):

1. Auto Immune Deficiency Syndrome (AIDS) or the HIV virus;

2. Cancer (including cancer of the stomach and liver);

3. Hypertension;

4. Diabetes?

as the average white person?

1. More likely

2. Just as likely

3. Less likely

8. (Don’t know)

9. (Refused)

________________________________________________________________________

18. When going to the doctor or health clinic for health care services, do you think most

Asian American/ Pacific Islanders receive the same quality of health care as whites, higher quality of care or lower quality of health care as most whites?

1. Same quality

2. Higher quality

3. Lower quality

8. (Don’t know)

9. (Refused)

_______________________________________________________________________

19. How big a problem do you think:

1. being able to afford the cost of health insurance and necessary medical care;

2. having enough doctors and other health providers near where they live;

3. having difficulty getting care because of their race or ethnic background is for the average Asian American/ Pacific Islander;

is for the average Asian American/ Pacific Islander? Is this a major problem, a minor problem or not a problem at all for the average Asian American/ Pacific Islander?

1. Major problem

2. Minor problem

3. Not a problem at all

8. (Don’t know)

9. (Refused)

________________________________________________________________________

20. Do you think the average Asian American/ Pacific Islander is better off, worse off or just as well off as the average white person in terms of:

1. how healthy they are;

2. getting routine medical care when they need it;

3. getting specialized treatments or surgery when they need it;

4. having health insurance?

1. Better off

2. Worse off

3. Just as well off

8. (Don’t know)

9. (Refused)

________________________________________________________________________

I have one last set of questions to help us better understand the people who participate in our survey.

21. Respondent’s gender

1. Male

2. Female

________________________________________________________________________

22. Are you currently married, living as married, widowed, divorced, separated, or have you never been married?

1. Married

2. Living as married

3. Widowed

4. Divorced

5. Separated

6. Never married

9. (Refused)

________________________________________________________________________

23. What is your age?

18-98 Record number

99 (Refused)

________________________________________________________________________

24. What is the last year or grade of school you completed?

1. Grade 8 or lower

2. High school incomplete

3. High school diploma or equivalent

4. Business, technical or vocational school after high school

5. Some college, no degree

6. Two-year or associate’s college degree

7. Four-year college degree

8. Graduate or professional school after college

99. (Refused)

________________________________________________________________________

25. In general, how would you describe your own health? Would you say it is excellent, very good, good, fair or poor?

1. EXCELLENT

2. VERY GOOD

3. GOOD

4. FAIR

5. POOR

8. (DON’T KNOW)

9. (REFUSED)

26. Are you yourself of Hispanic, Latino or Spanish origin?

1. Yes

2. No

8. (Don’t know)

9. (Refused)

________________________________________________________________________

27. What is your race?

1. White

2. Black or African American

3. Asian American/ Pacific Islander

4. Other (SPECIFY _________________________)

8. (Don’t know)

9. (Refused)

NO INCENTIVE

Thank you very much for participating in this interview. The information you have provided will be useful to policymakers in assessing awareness of health disparities. Do you have anything else to add, or do you have any questions? Again, thank you for your participation.

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