Follow up Survey

OMB No. 0990-

Exp Date

XX/XX/20XX

Follow –Up Survey (DIFO) Doing It For Ourselves

Program

Doing It For Ourselves (DIFO) Follow-Up Survey

Thank you for participating in this important survey! This information will help us understand the effectiveness of the DIFO health program. Some survey questions may be difficult to answer, but please respond to the items as best you can.

Name:

Date:

Section I – DIFO Program

Looking back on your involvement in the DIFO program, please indicate how helpful each component of the program was.

Components	Not helpful	Somewhat helpful	Very helpful
Your personal health coach Name of coach:
The group format and support
The facilitator of the group Name of facilitator:
The information about nutrition
The discussions of lesbian/bisexual women’s stressors
The discussion and practices of mindfulness
The physical activity routines
The written materials
The video clips
Other (please specify):

11. What did you personally find the most helpful?

12. What did you personally find the least helpful?

13. What made this program different from other health programs or groups you have been involved with?

14. Did you meet your personal goals for the program?

	Yes, completely
	Yes, partially
	No

15. If you did not completely meet your goals, which goals were challenging to meet? What specific challenges did you encounter?

Section II – Relationships and Identity

Please respond to each item to the best of your ability.

16. Which of the following best describes your present relationship?
    
    

	In a committed relationship with a woman (for example,
	cohabiting, domestic partnership, or legally married)
	In a committed relationship with a man (for example,
	cohabiting, domestic partnership, or legally married)
	Single, but somewhat involved with a woman, man, or both
	Single, and not involved with anyone

For questions 17-55, please indicate your agreement or disagreement with each of the following statements. Please do your best to complete each item. Some statements may depict situations that you have not experienced; please imagine yourself in those situations when answering those statements.

1	2	3	4	5	6	7
Strongly	Moderately	Slightly		Slightly	Moderately	Strongly
Disagree	Disagree	Disagree	Neutral	Agree	Agree	Agree
I try not to give signs that I am a lesbian/bisexual woman. I am careful about the way I dress, the jewelry I wear, the places, people and events I talk about.
I can’t stand lesbians who are too “butch”. They make lesbians as a group look bad.
Attending lesbian/gay/bisexual events and organizations is important to me.
I hate myself for being attracted to other women.
I believe female homosexuality is a sin.
I am comfortable being an “out” lesbian/bisexual woman. I want others to know and see me as a lesbian/bisexual woman.
I have respect and admiration for other lesbians/bisexual women
I wouldn’t mind if my boss knew that I was a lesbian/bisexual woman.
If some lesbians would change and be more acceptable to the larger society, lesbians as a group would not have to deal with so much negativity and discrimination.
I am proud to be a lesbian/bisexual woman.
I am not worried about anyone finding out that I am a lesbian/bisexual woman.
When interacting with members of the lesbian/gay/bisexual community, I often feel different and alone, like I don’t fit in.
I feel bad for acting on my lesbian desires.
I feel comfortable talking to my heterosexual friends about my everyday home life with my female partner/lover or my everyday activities with my lesbian/bisexual friends.
Having lesbian/bisexual friends is important to me.
I am familiar with lesbian/gay/bisexual books and/or magazines.
Being a part of the lesbian/gay/bisexual community is important to me.
It is important for me to conceal the fact that I am a lesbian/bisexual from my family.
I feel comfortable talking about homosexuality in public.
I live in fear that someone will find out I am a lesbian/bisexual woman.
If I could change my sexual orientation and become heterosexual, I would.
I do not feel the need to be on guard, lie, or hide my lesbianism/ bisexuality to others.
I feel comfortable joining a lesbian/gay/bisexual social group, sports team, or organization.
When speaking of my female lover/partner to a straight person I change pronouns so that others will think I’m involved with a man rather than a woman.
Being a lesbian/bisexual woman makes my future look bleak and hopeless.
If my peers knew of my lesbianism/bisexuality, I am afraid that many would not want to be friends with me.
Social situations with other lesbians/bisexual women make me feel uncomfortable.
I wish some lesbians wouldn’t “flaunt” their lesbianism. They only do it for shock value and it doesn’t accomplish anything positive.
I don’t feel disappointment in myself for being a lesbian/bisexual woman.
I am familiar with lesbian/gay/lesbian movies and/or music.
I am aware of the history concerning the development of lesbian/gay/bisexual communities and/or the lesbian/gay/bisexual rights movement.
I act as if my female lovers are merely friends.
I feel comfortable discussing my lesbianism/bisexuality with my family.
I could not confront a straight friend or acquaintance if she or he made a homophobic or heterosexist statement to me.
I am familiar with lesbian music festivals and conferences.
When speaking of my female lover/partner to a straight person, I often use neutral pronouns so the sex of the person is vague.
Lesbians are too aggressive.
I frequently make negative comments about other lesbians/bisexual women.
I am familiar with community resources for lesbians/bisexual woman (i.e., bookstores, support groups, bars, etc).

The following set of questions asks about your relationships and your social network, both in general and regarding your connection to the LGBT community.

56. How satisfied are you with your current relationship status?

	Very satisfied
	Somewhat satisfied
	Somewhat dissatisfied
	Very dissatisfied

57. How satisfied are you with the support you receive from your current social network of friends?

	Very satisfied
	Somewhat satisfied
	Not satisfied nor unsatisfied
	Somewhat dissatisfied
	Very dissatisfied

58. How closely connected do you feel to your local lesbian and/or bisexual women’s community?

	Very closely connected
	Closely connected
	Somewhat connected
	Not very connected
	Not at all connected

59. How closely connected do you feel to your local LGBT community?

	Very closely connected
	Closely connected
	Somewhat connected
	Not very connected
	Not at all connected

Section III – Health

The following set of questions asks about your physical, mental and emotional health.

60. Have you had at least one menstrual period in the past 12 months? (Please do not include bleedings caused by medical conditions, hormone therapy, or surgeries.)

	Yes
	No

61. Do you have a long-term physical or mental impairment that substantially limits one or more major life activities?
    
    

	Yes
	No

62. If yes, in which activities are you limited? [Check all that apply]:

	Caring for myself
	Performing manual tasks
	Walking or standing
	Lifting or reaching
	Seeing
	Hearing, speaking or communicating
	Learning, thinking or concentrating
	Working

In the past week	Rarely or none of the time (less than 1 day)	Some or a little of the time (1-2 days)	Occasionally or a moderate amount (3-4 days)	Most or all of the time (5-7 days)
I felt depressed
I felt lonely
I had crying spells
I felt sad

67. Do you NOW smoke every day, some days or not at all?

	Every day
	Some days
	Not at all

68. If you have quit smoking, how long has it been since you quit smoking cigarettes?

	Less than one year ago
	One year or longer
	Not Applicable

For 69- 71: By a drink we mean half an ounce of absolute alcohol (e.g., a 12 ounce can or glass of beer or cooler, a 5 ounce glass of wine, or a drink containing 1 shot of liquor).

69. During the last 30 days, how often did you usually have any kind of drink containing alcohol? Choose only one.

	Every day
	5 to 6 times a week
	3 to 4 times a week
	Twice a week
	Once a week
	2 to 3 times a month
	Once a month
	I did not drink any alcohol in the past month, but I did drink
	in the past (skip to question 72)
	I never drank any alcohol in my life (skip to question 72)

70. During the last 30 days, how many alcoholic drinks did you have on a typical day when you drank alcohol?

	25 or more drinks		7 to 8 drinks
	19 to 24 drinks		5 to 6 drinks
	16 to 18 drinks		3 to 4 drinks
	12 to 15 drinks		2 drinks
	9 to 11 drinks		1 drink

71. During the last 30 days, how often did you have 4 or more drinks containing any kind of alcohol in within a two-hour period? Choose only one.

	Every day		One day a week
	5 to 6 days a week		2 to 3 days a month
	3 to 4 days a week		One day a month
	Two days a week		Never

72. Do you consider yourself in recovery from alcohol or drug use?

	Yes
	No

The following questions ask for your views about your health—how you feel and how well you are able to do your usual activities. There are no right or wrong answers; please choose the answer that best fits your life right now.

73. In general, would you say your health is:

	Excellent
	Very good
	Good
	Fair
	Poor

The following questions are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?

74. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling or playing golf?

	Yes, limited a lot
	Yes, limited a little
	No, not limited at all

75. Climbing several flights of stairs

	Yes, limited a lot
	Yes, limited a little
	No, not limited at all

During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health?

76. Accomplished less than you would like.

	No, none of the time
	Yes, a little of the time
	Yes, some of the time
	Yes, most of the time
	Yes, all of the time

77. Were limited in the kind of work or other activities.

	No, none of the time
	Yes, a little of the time
	Yes, some of the time
	Yes, most of the time
	Yes, all of the time

During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)?

78. Accomplished less than you would like.
    
    

	No, none of the time
	Yes, a little of the time
	Yes, some of the time
	Yes, most of the time
	Yes, all of the time

79. Didn’t do work or other activities as carefully as usual

	No, none of the time
	Yes, a little of the time
	Yes, some of the time
	Yes, most of the time

80. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)?

	Not at all
	A little bit
	Moderately
	Quite a bit
	Extremely

These questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling.

81. How much of the time during the past 4 weeks have you felt calm and peaceful?

	All of the time
	Most of the time
	A good bit of the time
	Some of the time
	A little of the time
	None of the time

82. How much of the time during the past 4 weeks did you have a lot of energy?

	All of the time
	Most of the time
	A good bit of the time
	Some of the time
	A little of the time
	None of the time

83. How much of the time during the past 4 weeks have you felt downhearted and blue?

	All of the time
	Most of the time
	A good bit of the time
	Some of the time
	A little of the time
	None of the time

84. During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)?
    
    

	All of the time
	Most of the time
	Some of the time
	A little of the time
	None of the time

85. Compared to one year ago, how would you rate your physical health in general now?

	Much better
	Slightly better
	About the same
	Slightly worse
	Much worse

86. Compared to one year ago, how would you rate your emotional problems (such as feeling anxious, depressed or irritable) now?

	Much better
	Slightly better
	About the same
	Slightly worse
	Much worse

How much do you currently weigh?

lbs.

Section IV – Nutrition

We are now interested in understanding a little bit about your eating and drinking habits.

Please select one option for each of the following items:

	Never/ Rarely	Some -times	Often	Usually/ Always	N/A
I notice when there are subtle flavors in the foods I eat
When eating a pleasant meal, I notice if makes me feel relaxed
I snack without noticing that I am eating
I appreciate the way my food looks on my plate
When I’m feeling stressed at work, I’ll go find something to eat
When I’m sad, I eat to feel better
I notice when foods and drinks are too sweet
Before I eat I take a moment to appreciate the colors and smells of my food
I taste every bite of food that I eat
I notice when the food I eat affects my emotional state
I have trouble not eating ice cream, cookies, or chips if they’re around the house

The next section is about the foods you ate or drank during the past month, that is, the past 30 days, including meals and snacks. Remember to include any sweetened beverages used as a mixer.

99. During the past month, how many times per day, week or month did you drink 100% PURE fruit juices? Do not include fruit-flavored drinks with added sugar or fruit juice you made at home and added sugar to. Only include 100% juice.

Times per (circle one):

Day

Week

Month

Don’t know

100. During the past month, not counting juice, how many times per day, week or month did you eat fruit? Count fresh, frozen or canned fruit.

Times per (circle one):

Day

Week

Month

Don’t know

101. During the past month, how many times per day, week or month did you eat cooked or canned beans, such as refried, black, garbanzo beans, beans in soup, soybeans, edamame, tofu or lentils. Do NOT include long green beans.

Times per (circle one):

Day

Week

Month

Don’t know

102. During the past month, how many times per day, week or month did you eat dark green vegetables, for example, broccoli or dark leafy greens including romaine, chard, collard greens or spinach?

Times per (circle one):

Day

Week

Month

Don’t know

103. During the past month, how many times per day, week or month did you eat orange colored vegetables such as sweet potatoes, pumpkin, winter squash or carrots?

Times per (circle one):

Day

Week

Month

Don’t know

104. Not counting questions 101-103 during the past month, about how many times per day, week or month did you eat OTHER vegetables? Examples of other vegetables include tomatoes, tomato juice or V-8 juice, corn, eggplant, lettuce, cabbage and white potatoes that are not fried such as baked or mashed potatoes.

Times per (circle one):

Day

Week

Month

Don’t know

105. How many servings of fruits and vegetables do you usually have per day? (1 serving = 1 medium piece of fruit; ½ cup fresh, frozen or canned fruits/ vegetables; ¾ cup fruit/vegetable juice; 1 cup salad greens; or ¼ cup dried fruit)

	0 servings per day
	1-2 servings per day
	3-4 servings per day
	5 or more servings per day

106. During the past month, how often did you drink regular soda or pop that contains sugar? Do not include diet soda.

Times per (circle one):

Day

Week

Month

Don’t know

107. During the past month, how often did you drink diet soda?

Times per (circle one):

Day

Week

Month

Don’t know

108. During the past month, how often did you drink sports or energy drinks such as Gatorade, Red Bull and Vitamin Water? Remember to include sports or energy drinks used as a mixer. Do not include diet or sugar-free kinds.

Times per (circle one):

Day

Week

Month

Don’t know

109. During the past month, how often did you drink sweetened fruit drinks such as Kool-aid, cranberry drink and lemonade? Include fruit drinks you made at home and added sugar to. Do not include 100% fruit juices and drinks with things like Splenda or Equal.

Times per (circle one):

Day

Week

Month

Don’t know

110. During the past month, how often did you drink coffee or tea with sugar or honey added? Do not include drinks with things like Splenda or Equal. Include pre-sweetened tea and coffee drinks such as Arizona Iced Tea and Frappuccino.

Times per (circle one):

Day

Week

Month

Don’t know

111. During the past month, how often did you drink water (including tap, bottled, and carbonated water)?

	Never or Less than 1 time per week (skip to question 113)
	1 – 2 times per week
	3 – 4 times per week
	5 - 6 times per week
	1 time per day
	2 to 3 times per day
	4 – 5 times per day
	6 or more times per day

112. Each time you drank water, how much did you usually drink?

	Less than 6 fl oz (3/4 oz)
	8 fl oz (1 cup)
	12 fl oz (1-1/2 cups)
	16 fl oz (2 cups)
	More than 20 fl oz (2-1/2 cups)

Section V – Physical Activity

Physical activities are activities where you move and increase your heart rate above its resting rate, whether you do them for pleasure, work, or transportation.

The following questions ask about the amount and intensity of physical activity you usually do. The intensity of the activity is related to the amount of energy you use to do these activities.

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.

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

	days per week
	No vigorous physical activities (skip to Question 115)

114. How much time did you usually spend doing vigorous physical activities on one of those days?

	hours per day
	minutes per day
	Don’t know/Not sure

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.

115. 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.

	days per week
	No moderate physical activities (skip to question 117)

116. How much time did you usually spend doing moderate physical activities on one of those days?

	hours per day
	minutes per day
	Don’t know/Not sure

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 might do solely for recreation, sport, exercise, or leisure.

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

	days per week
	None (skip to question 119)

118. How much time did you usually spend walking on one of those days?

	hours per day
	minutes per day
	Don’t know/Not sure

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.

119. During the last 7 days, how much time did you spend sitting on a week day?

	hours per day
	minutes per day
	Don’t know/Not sure

Thank you so much for your participation! Your input is critical to this study.

B.3-22