12-month Follow up Assessment Survey

Out, Proud and Healthy Fitness Project

19116_ID Out Proud and Healthy Fitness- 12-month Follow-up Assessment Survey

12-month Follow up Assessment Survey

OMB: 0990-0411

Document [docx]

Download: docx | pdf

Form Approved

OMB No. 0990-

12-Month Follow-Up OWH Out, Proud, and Healthy (OPAH) Exp. Date XX/XX/20XX

12-Month Follow-Up

Assessment Survey

Stress Jackson Heart Study

We are interested in the amount of stress that you have experienced over the past 12 months. Please rate the stress in different parts of your life (in column 1) by CIRCLING the letter in the columns on the right that best represents your level of stress in the past 12 months.

Over the Past 12 months, how much stress did you experience:

Not Stressful

Mildly Stressful

Moderately Stressful

Very Stressful

Does Not Apply

1. In your job? (This would include feeling overworked, hassled at work, job insecurity, etc.)

2. In your relationships with others? (This would include your marriage, friendships, dealing with relatives, etc.)

3. Related to living in your neighborhood? (This would include crime, traffic, events affecting your personal safety, etc.)

4. Related to caring for others? (This would include caring for an elderly parent or relative, caring for children, etc.)

5. Related to legal problems? (This would include dealing with lawyers, judges, or other court officials, being accused or convicted of crime, etc.)

6. Related to medical problems? (This would include personal health problems or illness in the family, availability of health care, etc.)

7. Related to racism and discrimination? (This would include feeling mistreated or discriminated against at work, in a restaurant, at the grocery store, etc).

8. Related to meeting basic needs? (This would include housing, buying food, paying bills, etc.)

Perceived Stress Scale

The following questions ask you about your feelings and thoughts DURING THE LAST MONTH. In each case, check the box indicating how often you felt or thought that way.

	Very often	Fairly often	Some times	Almost never	Never
In the last month, how often have you been upset because of something that happened unexpectedly
In the last month, how often have you felt that you were unable to control the important things in your life.
In the last month, how often have you felt nervous and “stressed?”
In the last month, how often have you felt confident about your ability to handle your personal problems?
In the last month, how often have you felt that things were going your way?
In the last month, how often have you found that you could NOT cope with all things that you had to do?
In the last month, how often have you been able to control irritations in your life?
In the last month, how often have you felt that you were on top of things?
In the last month, how often have you been angered because of things that were outside of your control?
In the last month, how often have you felt difficulties were piling up so high that you could not overcome them?

Connor-Davidson Resiliency Scale (CD-RISC)*

Please indicate how much you agree with the following statements as they apply to you over the last month. If a particular situation has not occurred recently, answer according to how you think you would have felt.

	Not true at all	Rarely true	Sometimes true	Often true	True nearly all the time
I am able to adapt when changes occur	1	2	3	4	5
I can deal with whatever comes my way	1	2	3	4	5
I try to see the humorous side of things when I am faced with problems	1	2	3	4	5
Having to cope with stress can make me stronger	1	2	3	4	5
I tend to bounce back after illness, injury, or other hardships	1	2	3	4	5
I believe I can achieve my goals, even if there are obstacles	1	2	3	4	5
Under pressure, I stay focused and think clearly	1	2	3	4	5
I am not easily discouraged by failure	1	2	3	4	5
I can usually find something to laugh about	1	2	3	4	5
I think of myself as a strong person when dealing with life’s challenges and difficulties	1	2	3	4	5
I am able to handle unpleasant or painful feelings like sadness, fear and anger	1	2	3	4	5

Center for Epidemiologic Studies Depression (CES-D) Scale

Below is a list of the ways you might have felt or behaved. Mark how often you have felt this way during the past week.

In the past week:	Rarely or none of the time (less than 1 day)	Some of a little of the time (1-2 days)	Occasionally or a moderate amount of time (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

Social Support for Diet and Exercise Behaviors

The following questions refer to social support for your eating habits and physical activity.

Below is a list of things people might do or say to someone who is trying to improve their eating habits. We are interested in high fat and high salt (or high sodium) foods. If you are not trying to make any of these dietary changes, then some of the questions may not apply to you. Please read and give an answer to every question.

Please rate each question twice. Under family, check the box that describes how often any living in your household has said or done what is described DURING THE LAST MONTH. Under friends, check the box tat describes how often your friends, acquaintances, or coworkers have said or done what is described DURING THE LAST MONTH.

During the last month, my family (or members of my household) OR friends	None	Rarely	A few Times	Often	Very Often	Does Not Apply
Encouraged me not to eat “unhealthy foods” (cake, salted chips) when I’m tempted to do so
Family
Friends
Discussed my eating habit changes with me (asked me how I’m doing with my eating changes)
Family
Friends
Reminded me not to eat high fat, high salt foods
Family
Friends
Complimented me on changing my eating habits (“Keep it up,” “We are proud of you”)
Family
Friends
Commented if I went back to my old eating habits
Family
Friends
Ate high fat or high salt foods in front of me
Family
Friends
Refused to eat the same foods I eat
Family
Friends
Brought home foods I’m trying not to eat
Family
Friends
Got angry when I encouraged them to eat low salt, low fat foods
Family
Friends
Offered me food I’m trying not to eat
Family
Friends

Below is a list of things people might do or say to someone who is trying to improve their physical activity level. If you are not trying to make any physical activity changes, then some of the questions may not apply to you. Please read and give an answer to every question.

Please rate each question twice. Under family, check the box that describes how often any living in your household has said or done what is described DURING THE LAST MONTH. Under friends, check the box that describes how often your friends, acquaintances, or coworkers have said or done what is described DURING THE LAST MONTH.

During the last month, my family (or members of my household) OR friends	None	Rarely	A few Times	Often	Very Often	Does Not Apply
Did physical activities with me
Family
Friends
Offered to do physical activities with me
Family
Friends
Gave me helpful reminders to be physically active (i.e., “Are you going to do your activity tonight?”)
Family
Friends
Gave me encouragement to stick with my activity program
Family
Friends
Changed their schedule so we could do physical activity together
Family
Friends
Discussed physical activity with me
Family
Friends
Complained about the time I spent doing physical activity
Family
Friends
Criticized me or made fun of me doing physical activity
Family
Friends
Gave me rewards for being physically active such as bought or game me something I liked
Family
Friends
Planned for physical activities on recreational outings
Family
Friends
Helped plan events around my physical activities
Family
Friends
Asked me for ideas on how they can be more physically active
Family
Friends
Talked about how much they like to do physical activity
Family
Friends

International Physical Activity Questionnaire (IPAQ) – Short*

Shape51

We are interested in finding out about the kinds of physical activities that people do as part of their everyday lives. The questions will ask you about the time you spent being physically active in the last 7 days. Please answer each question even if you do not consider yourself to be an active person. Please think about the activities you do at work, as part of your house and yard work, to get from place to place, and in your spare time for recreation, exercise or sport.

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.

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

Shape52

Shape53 No vigorous physical activities Skip to question 3

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

_____ hours per day

_____ minutes per day

Shape54

Don’t know/Not sure

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.

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

Shape55

Shape56 No moderate physical activities Skip to question 5

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

_____ hours per day

_____ minutes per day

Shape57

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.

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

_____ days per week

Shape58

Shape59 No walking Skip to question 7

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

_____ hours per day

_____ minutes per day

Shape60

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.

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

_____ hours per day

_____ minutes per day

Shape61

Don’t know/Not sure

Exercise Self-Efficacy

Whether you exercise or not, please rate how confident you are that you could really motivate yourself to do things like these consistently, for at least six months.

How sure are you that you can do these things?	I know I cannot	Maybe I can	I know I can
Get up early, even on weekends, to exercise
Stick to your exercise program after a long, tiring day at work
Exercise even though you are feeling depressed
Set aside time for a physical activity program; that is, walking, jogging, swimming, biking, or other continuous activities for at least 30 minutes, 5 times a week
Continue to exercise with others even though they seem too fast or slow for you
Stick to your exercise program when undergoing a stressful life change (e.g., death of the family, moving)
Attend a party only after exercising
Stick to your exercise program when your family/friends are demanding more time from you
Stick to your exercise program when you have household chores to attend to
Stick to your exercise program when you have excessive demands at work
Stick to your exercise program when social obligations are very time consuming
Read or study less in order to exercise more

Barriers to Exercise Scale

The following items reflect situations that are listed as common reasons for preventing individuals from participating in exercise sessions or, in some cases, dropping out. Using the scales below please indicate how confident you are that you could exercise in the event that any of the following circumstances were to occur.

Please indicate the degree to which you are confident that you could exercise in the event that any of the following circumstances were to occur by circling the appropriate %. To the right of each statement, put an ‘X’ in the column with the response that most closely matches your own, remembering that there are no right or wrong answers.

I believe I could exercise 5 times per week (at least 150 minutes of moderate physical activity) for the next 3 months if:

Statement	Not at all confident 0%	10%	20%	30%	40%	Moderately confident 50%	60%	70%	80%	90%	Highly confident 100%
The weather was very bad (hot, humid, rainy, cold).
I was bored by the program or activity.
I was on vacation.
I was not interested in the activity.
I felt pain or discomfort when exercising.
I had to exercise alone.
It was not fun or enjoyable.
It became difficult to get to the exercise location.
I don’t like the particular activity program that I was involved in.
My schedule conflicted with my exercise session.
I felt self-conscious about my appearance when I exercised.
An instructor does not offer me any encouragement.
I was under personal stress of some kind.

Motive for Physical Activities Questionnaire

The following is a list of reasons why people engage in physical activities, sports and exercise. Keeping in mind your primary physical activity or sport, respond to each question (using the scale given) on the basis of how true that response is for you.

1-7 scale; 1= not at all true for me, 7= very true for me

____1. I do not engage in any physical activities, sports or exercise (skip to the next section)

___ 2. Because I want to be physically fit.

___ 3. Because it’s fun.

___ 4. Because I like engaging in activities which physically challenge me.

___ 5. Because I want to obtain new skills.

___ 6. Because I want to look or maintain weight so I look better.

___ 7. Because I want to be with my friends.

___ 8. Because I like to do this activity.

___ 9. Because I want to improve existing skills.

___ 10. Because I like the challenge.

___ 11. Because I want to define my muscles so I look better.

___ 12. Because it makes me happy.

___ 13. Because I want to keep up my current skill level.

___ 14. Because I want to have more energy

___ 15. Because I like activities which are physically challenging.

___ 16. Because I like to be with others who are interested in this activity.

___ 17. Because I want to improve my cardiovascular fitness.

___ 18. Because I want to improve my appearance.

___ 19. Because I think it’s interesting.

___ 20. Because I want to maintain my physical strength to live a healthy life.

___ 21. Because I want to be attractive to others.

___ 22. Because I want to meet new people.

___ 23. Because I enjoy this activity.

___ 24. Because I want to maintain my physical health and well-being.

___ 25. Because I want to improve my body shape.

___ 26. Because I want to get better at my activity.

___ 27. Because I find this activity stimulating.

___ 28. Because I will feel physically unattractive if I don’t.

___ 29. Because my friends want me to.

___ 30. Because I like the excitement of participation.

___ 31. Because I enjoy spending time with others doing this activity.

Veterans RAND 36 Item Health Survey (VR-36)*

Instructions: This survey asks for your views about your health. This information will help keep track of how you feel and how well you are able to do your usual activities.

Please answer every question by filling in one circle on each line. If you are unsure about how to answer a question, please give the best answer you can.

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

EXCELLENT

VERY GOOD

GOOD

FAIR

POOR

2. 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?

	YES, LIMITED A LOT	YES, LIMITED A LITTLE	NO, NOT LIMITED AT ALL
a. Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports?	0	0	0
b. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf?	0	0	0
c. Lifting or carrying groceries?	0	0	0
d. Climbing several flights of stairs?	0	0	0
e. Climbing one flight of stairs?	0	0	0
f. Bending, kneeling, or stooping?	0	0	0
g. Walking for than a mile?	0	0	0
h. Walking several blocks?	0	0	0
i. Walking one block?	0	0	0
j. Bathing or dressing yourself?	0	0	0

3. 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?

	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
a. Cut down the amount of time you spent on work or other activities.	0	0	0	0	0
b. Accomplished less than you would like.	0	0	0	0	0
c. Were limited in the kind of work or other activities.	0	0	0	0	0
d. Had difficulty performing the work or other activities (for example, it took extra effort).	0	0	0	0	0

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

	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
a. Cut down the amount of time you spent on work or other activities.	0	0	0	0	0
b. Accomplished less than you would like.	0	0	0	0	0
c. Were limited in the kind of work or other activities.	0	0	0	0	0

5. During the past 4 weeks, to what extent has your physical health or emotional problems interfered with your normal social activities with family, friends, neighbors, or groups?

NOT AT ALL

SLIGHTLY

MODERATELY

QUITE A BIT

EXTREMELY

6. How much bodily pain have you had during the past 4 weeks?

NONE

VERY MILD

MILD

MODERATE

SEVERE

VERY SEVERE

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

NOT AT ALL

A LITTLE BIT

MODERATELY

QUITE A BIT

EXTREMELY

8. 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. How much of the time during the past 4 weeks:

	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
a. Do you feel full of pep?	0	0	0	0	0	0
b. Have you been a very nervous person?	0	0	0	0	0	0
c. Have you felt so down in the dumps that nothing could cheer you up?	0	0	0	0	0	0
d. Have you felt calm and peaceful?	0	0	0	0	0	0
e. Did you have a lot of energy?	0	0	0	0	0	0
f. Have you felt downhearted and blue?	0	0	0	0	0	0
g. Did you feel worn out?	0	0	0	0	0	0
h. Have you been a happy person?	0	0	0	0	0	0
i. Did you feel tired?	0	0	0	0	0	0

9. 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

10. Please choose the answer that best describes how true or false each of the following statements is for you.

	DEFINITELY TRUE	MOSTLY TRUE	NOT SURE	MOSTLY FALSE	DEFINITELY FALSE
a. I seem to get sick a lot easier.	0	0	0	0	0
b. I am as healthy as anybody I know.	0	0	0	0	0
c. I expect my health to get worse.	0	0	0	0	0
d. My health is excellent.	0	0	0	0	0

Now we’d like to ask you some questions about how your health may have changed.

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

MUCH

BETTER

SOMEWHAT

BETTER

ABOUT THE

SAME

SOMEWHAT

WORSE

MUCH

WORSE

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

MUCH

BETTER

SOMEWHAT

BETTER

ABOUT THE

SAME

SOMEWHAT

WORSE

MUCH

WORSE

Eating Out and Food/Drink Consumption Questions

Next, we have some questions about your eating habits and about meals. Meals means breakfast, lunch and dinner.

In general, how healthy is your overall diet? Would you say …..

Excellent

Very good

Good

Fair

Poor

Don’t Know

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?

___________

Number of meals

How many of those meals did you get from a fast-food or pizza place?

___________

Number of meals

Some grocery stores sell “ready to eat” foods such as salads, soups, chicken, sandwiches and cooked vegetables in their salad bars and deli counters.

During the past 30 days, how often did you eat “ready to eat” foods from the grocery store? [Please do not include sliced meat or cheese you buy for sandwiches and frozen or canned foods.]

Circle the unit

___________ per day or per week or per month

Number of times

During the past 30 days, how often did you eat frozen meals or frozen pizzas?

Circle the unit

___________ per day or per week or per month

*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.