Form 0917-Mashpee Mashpee Wampanoag Indian Health Service Unit Community H

IHS Mashpee Community Health Assessment Survey
Please take a few minutes to complete the survey below. The purpose of this survey is to get your opinions about
community health issues. Information gathered in this survey will help the Mashpee Wampanoag Health Service Unit
identify community health priorities and develop a community health improvement plan. Your response will remain
confidential and will be aggregated to maintain anonymity. Thank you for your time.
General Health
1. Would you say that in general your health is excellent, good, fair or poor?
a. Excellent
b. Good
c. Fair
d. Poor
Access to Health Care
2. Do you have one person you think of as your personal doctor or health care provider?
a. Yes, only one
b. More than one
c. No
3. Where would you go for health care if you became sick in the next 2 weeks? (Select all that apply):
a. A traditional Native or Indian healer
b. Tribal Health Program
c. The Mashpee Wampanoag Health Service Unit-IHS
d. A health maintenance organization (HMO) clinic or private doctor’s office
e. A county, community, or government clinic
f. A veterans hospital, military hospital, or military clinic
g. A hospital emergency room
h. An urgent care clinic
i. A complementary healer like a homeopaths, naturopath, herbalist, acupuncturist, or chiropractor
j. Nowhere
4. What type of health care coverage do you use to pay for your medical care? (Select all that apply):
a. Your employer
b. Someone else’s employer
c. A plan that you or someone else buys on your own
d. Medicare
e. Medicaid (MassHealth)
f. Commonwealth Care
g. The military, TriCare, the VA [or CHAMP-VA]
h. The Indian Health Service
i. Some other source
j. None
k. Unsure
l. Pay cash (no insurance)
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5. About how long has it been since you last visited a doctor for a routine checkup? (A
routine checkup is a general physical exam, not an exam for a specific injury, illness, or
condition.)
a. Within the past year (anytime less than 12 months ago)
b. Within the past 2 years (1 year but less than 2 years ago)
c. Within the past 5 years (2 years but less than 5 years ago)
d. 5 or more years ago
e. Never
6. What is the main reason you did not get a routine check-up in the past year?
a. No reason/never thought of it
b. Do not think I need a check-up
c. No health insurance/costs too much
d. Do not have transportation to get to the check-up
e. Do not have the time for a check-up
f. Too painful, unpleasant or embarrassing
g. Could not find a doctor of the same gender
h. Do not want to know the results
i. Do not trust health care providers
Oral Health
7. How long has it been since you last visited a dentist or a dental clinic for any reason, including visits to dental
specialists, such as orthodontists?
a. Within the past year (anytime less than 12 months ago)
b. Within the past 2 years (over 1 year, but less than 2 years ago)
c. Within the past 5 years (over 2 years, but less than 5 years ago)
d. 5 or more years ago
e. Never
8. What is the main reason you did not get a dental checkup in the past year?

a.
b.
c.
d.
e.
f.
g.
h.
i.

No reason/never thought of it
Do not think I need a check-up
No health insurance/costs too much
Do not have transportation to get to the check-up
Do not have the time for a check-up
Too painful, unpleasant or embarrassing
Could not find a dentist of the same gender
Do not want to know the results
Do not trust health care providers

Height and Weight
9.

Please circle the best description for you:
a. I want to gain some weight
b. I want to lose some weight
c. I feel good about my weight
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Exercise
9.

During the past month, other than your regular job, did you participate in any physical activities or exercises
such as running, calisthenics, golf, gardening, or walking for exercise?
a. Yes
b. No

10. My activity level is best described as:
a. Little or no physical activity
b. 30 minutes of physical activity at least 4 times of week
c. 30 minutes of physical activity 5 or more times per week.
Diabetes
11.

Have you ever been told by a doctor or other health care professional that you have diabetes?
a. Yes
b. No

12.

How old were you when you were told you have diabetes?
a. Under 18
b. 18 or older

13.

About how many times in the past 12 months have you seen a doctor, nurse or other health professional for
your diabetes?
a. 2 or more
b. None
c. Unsure

High Blood Pressure
14.

Has a health care professional ever told you that you have high blood pressure?
a. Yes
b. No

High Cholesterol
15.

Has a health care professional ever told you that you have high cholesterol?
a. Yes
b. No

Women’s Health (Women Only)
Please complete the following questions if you are a female. Otherwise, please skip to Question 23.
16.

A clinical breast exam is when a doctor, nurse, or other health care professional feels the
breasts for lumps. Have you ever had a clinical breast exam?
a. Yes
b. No

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17.

A mammogram is an x-ray of each breast that is taken when checking for breast cancer. Have you ever had a
mammogram?
a. Yes
b. No

18.

Did you know CDC recommends women 50 to 74 years old and are at average risk for breast cancer to get a
mammogram every two years?
a. Yes
b. No

19. A Pap test is a test for cancer of the cervix. Have you ever had a Pap test?
a. Yes
b. No
20. Do you know according to the American College of Obstetrics and Gynecology women aged 21 to 29 years of age
should have a Pap test alone every three years?
a. Yes
b. No
21.

Do you know according to the American College of Obstetrics and Gynecology women aged 30 to 65 years
should have a Pap test and HPV test (co-testing) done every 5 years? (preferred)
a. Yes
b. No

Men’s Health (Men only)
Please complete the following questions if you are a male. Otherwise, please skip to Question 25.
22.

A Prostate-Specific Antigen test, also called a PSA test, is a blood test used to check
men for prostate cancer. Have you ever had a PSA test?
a. Yes
b. No

Mental Health
23.

Mental health includes stress, depression, and emotional problems. Over the last 2 weeks, how often have you
been bothered by any of the following: Little interest or pleasure in doing things and/or feeling down, depressed,
or hopeless?
a. Not at All
b. Several Days
c. More than half the days
d. Nearly every day

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24.

Has a doctor or other healthcare provider ever told you that you have an anxiety disorder (including acute stress
disorder, anxiety, generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, phobia,
posttraumatic stress disorder, or social anxiety disorder)?
a. Yes
b. No

25.

Has a doctor or other healthcare provider ever told you that you have a depressive
disorder (including depression, major depression, dysthymia, or minor depression)?
a. Yes
b. No

Tobacco Use
26. Please circle the best description for you (Exposure):
a. Smoke free home
b. Smoker in home
27. Please circle the best description for you (Smokeless-chewing/dip)
a. Current Smokeless
b. Never used smokeless
c. Previous(former)smokeless
28. Please circle the best description for you (Smoking
a. Never smoked
b. Ceremonial use only
c. Previous (former)smoker
d. Current Smoker
29. Alcohol Use

Do you drink alcohol?
a. Yes
b. No
If yes, please answer the following questions:
How often?
a. 1x per week
b. 1-7x per week
c. More than 7 times per week
30. Have you ever felt you should cut down your drinking?
a. Yes
b. No
31. Have you ever felt guilty or bad about your alcohol use
a. Yes
b. No

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Opioid Prescription Pain Medication Use
32. Do you use opioids (such as codeine, fentanyl, Dilaudid, Vicodin, methadone)
a. Yes
b. No
33. If yes, please answer the following questions.
Have you ever gone to your provider for chronic pain and received pain medicine?
a. Yes
b. No
34. Would you like to talk to a provider about how to get Narcan (Naloxone) a medication used to treat Opioid

Overdose?
a. Yes
b. No

Community Health
35. Have you had any falls in the last 6 months?
a. Yes
b. No

Demographic Questions
36.

What county do you live?
a. Barnstable
b. Bristol
c. Suffolk
d. Plymouth
e. Norfolk
f. I live outside these counties

37.

What is your gender?
a. Female
b. Male
c. I prefer not to answer

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38.

What best describes your age (in years)?
a. 25 or less
b. 26 to 50
c. 51 to 64
d. 65 or over

39. Education?
a. Less than high school
b. GED (High school graduate)
c. (Some college or technical school, including an associate’s degree)
d. 4 years or more of college (College graduate)
e. Graduate degree

40. What is your current employment status?
a. Employed for wages
b. Self-employed
c. Out of work
d. A homemaker
e. A student
f. Retired
g. Unable to work

41.

What best describes your housing situation
a. Safe and secure
b. Unaffordable
c. Transitional housing
d. Substandard housing
e. Homeless
f. Lives with relatives

42.

What best describes your access to Transportation
a. Needs are met through public transportation, car or regular ride
b. Needs are met some of the time through public transportation, car or regular ride
c. Needs rarely met

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43.

Do you need or utilize childcare?
a. Yes
b. No

44.

If you need or utilize childcare, what best describes you situation?
a. Child on waiting list for enrollment in Childcare
b. Childcare provided for by family member
c. Child enrolled in a licensed childcare setting.
d. I need child care

45.

What best describes your income level?
a. In Crisis
b. Vulnerable
c. Stable
d. Thriving

46.

47.

Overall, how satisfied or dissatisfied are you with our Service Unit-the Mashpee Wampanoag Health Service
Unit-Clinic
a. Very satisfied
b. Somewhat satisfied
c. Neither satisfied nor dissatisfied
d. Somewhat dissatisfied
e. Very dissatisfied
Have we improved your access to healthcare?
a. Yes
b. No
c. Sometimes
d. Maybe
e. Not sure

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48.

In the following list, what do you think are the three most important “risky behaviors” in our Community?
(Those behaviors, which have the greatest impact on overall community health.)
Select only three:
a.
b.
c.
d.
e.
f.
g.

49.

h. Racism
I. Tobacco use
J. Not using birth control
K. Not using seat belts/Child safety seats
I. Unsafe sex
M. Other___________

In the following list, what do you think are the three most important factors for a “Healthy Community”?
(Those factors, which most improve the quality of life in a community.)
Select only three:
a.
b.
c.
d.
e.
f.
g.
h.
i.

50.

Alcohol abuse
Being overweight
Dropping out of School
Drug abuse
Lack of exercise
Poor eating habits
Not getting “shots” to prevent disease

Good place to raise children
Low crime/safe neighborhoods
Low level of child abuse
Good schools
Access to health care (e.g. family doctor)
Parks and recreation
Clean environment
Affordable housing
Arts and cultural events

J. Excellent race relations
k. Good jobs and health economy
I. Strong family life
L. Healthy behaviors and lifestyles
M. Low adult death and disease rates
N. Low infant deaths
O. Religious or spiritual values
P. Other__________________

An appointment was available when I needed it.
a. Strongly Agree
b. Agree
c. Neutral
d. Disagree
e. Strongly Disagree
f. Not Applicable

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