Delaware Version 2008 Behavioral Risk Factor Surveillance System Questionnaire December 7, 2007 Behavioral Risk Factor Surveillance System 2008 Questionnaire Table of Contents Table of Contents Interviewer's Script Core Sections Section 1: Health Status Section 2: Healthy Days - Health-Related Quality of Life Section 3: Health Care Access Section 4: Sleep Section 5: Exercise Section 6: Diabetes Section 7: Oral Health Section 8: Cardiovascular Disease Prevalence Section 9: Asthma Section 10: Disability Section 11: Tobacco Use Section 12: Demographics Section 13: Alcohol Consumption Section 14: Immunization Section 15: Falls Section 16: Seatbelt Use Section 17: Drinking and Driving Section 18: Women's Health Section 19: Prostate Cancer Screening Section 20: Colorectal Cancer Screening Section 21: HIV/AIDS Section 22: Emotional Support and Life Satisfaction Optional Modules Module 1: Pre-Diabetes Module 2: Diabetes Module 6: Binge Drinking Module 7: Other Tobacco Products [STATE QUESTIONS ON TOBACCO USE HERE] Module 10: Adult Human Papilloma Virus (HPV) Module 15: Random Child Selection Module 17: Child Human Papilloma Virus (HPV) Closing Statement Interviewer's Script HELLO, I am calling for the Delaware Division of Public Health. My name is (first name) from the University of Delaware. We are gathering information about the health of Delaware residents. This project is conducted by the health department with assistance from the Centers for Disease Control and Prevention. Your telephone number has been chosen randomly, and I would like to ask some questions about health and health practices. Is this (phone number) ? If "no," Thank you very much, but I seem to have dialed the wrong number. It's possible that your number may be called at a later time. STOP Is this a private residence in (state) ? If "no," Thank you very much, but we are only interviewing private residences. STOP Is this a cellular telephone? [Read only if necessary: "By cellular telephone we mean a telephone that is mobile and usable outside of your neighborhood." If "yes," Thank you very much, but we are only interviewing land line telephones and private residences. STOP I need to randomly select one adult who lives in your household to be interviewed. How many members of your household, including yourself, are 18 years of age or older? __ Number of adults If "1," Are you the adult? If "yes," Then you are the person I need to speak with. Enter 1 man or 1 woman below (Ask gender if necessary). Go to page 5. If "no," Is the adult a man or a woman? Enter 1 man or 1 woman below. May I speak with [fill in (him/her) from previous question]? Go to "correct respondent" on the next page. How many of these adults are men and how many are women? __ Number of men __ Number of women The person in your household that I need to speak with is . If "you," go to page 4 To the correct respondent: HELLO, I am calling for the Delaware Division of Public Health. My name is (first name) from the University of Delaware. We are gathering information about the health of Delaware residents. This project is conducted by the health department with assistance from the Centers for Disease Control and Prevention. Your telephone number has been chosen randomly, and I would like to ask some questions about health and health practices. Core Sections I will not ask for your name, address, or other personal information that can identify you. You do not have to answer any question you do not want to, and you can end the interview at any time. Any information you give me will be confidential. If you have any questions about this survey, please call the Delaware Division of Public Health at 302-744-1000. Section 1: Health Status 1.1 Would you say that in general your health is- (73) Please read: 1 Excellent 2 Very good 3 Good 4 Fair Or 5 Poor Do not read: 7 Don't know / Not sure 9 Refused Section 2: Healthy Days - Health-Related Quality of Life 2.1 Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good? (74-75) _ _ Number of days 8 8 None 7 7 Don't know / Not sure 9 9 Refused 2.2 Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good? (76-77) _ _ Number of days 8 8 None [If Q2.1 and Q2.2 = 88 (None), go to next section] 7 7 Don't know / Not sure 9 9 Refused 2.3 During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation? (78-79) _ _ Number of days 8 8 None 7 7 Don't know / Not sure 9 9 Refused Section 3: Health Care Access 3.1 Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare? (80) 1 Yes 2 No 7 Don't know / Not sure 9 Refused 3.2 Do you have one person you think of as your personal doctor or health care provider? If "No," ask: "Is there more than one, or is there no person who you think of as your personal doctor or health care provider?" (81) 1 Yes, only one 2 More than one 3 No 7 Don't know / Not sure 9 Refused 3.3 Was there a time in the past 12 months when you needed to see a doctor but could not because of cost? (82) 1 Yes 2 No 7 Don't know / Not sure 9 Refused 3.4 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. (83) 1 Within past year (anytime less than 12 months ago) 2 Within past 2 years (1 year but less than 2 years ago) 3 Within past 5 years (2 years but less than 5 years ago) 4 5 or more years ago 7 Don't know / Not sure 8 Never 9 Refused Section 4: Sleep The next question is about getting enough rest or sleep. 4.1 During the past 30 days, for about how many days have you felt you did not get enough rest or sleep? (84-85) _ _ Number of days 8 8 None 7 7 Don't know / Not sure 9 9 Refused Section 5: Exercise 5.1 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? (86) 1 Yes 2 No 7 Don't know / Not sure 9 Refused Section 6: Diabetes 6.1 Have you ever been told by a doctor that you have diabetes? If "Yes" and respondent is female, ask: "Was this only when you were pregnant?" If respondent says pre-diabetes or borderline diabetes, use response code 4. (87) 1 Yes 2 Yes, but female told only during pregnancy 3 No 4 No, pre-diabetes or borderline diabetes 7 Don't know / Not sure 9 Refused Section 7: Oral Health 7.1 How long has it been since you last visited a dentist or a dental clinic for any reason? Include visits to dental specialists, such as orthodontists. (88) Read only if necessary: 1 Within the past year (anytime less than 12 months ago) 2 Within the past 2 years (1 year but less than 2 years ago) 3 Within the past 5 years (2 years but less than 5 years ago) 4 5 or more years ago Do not read: 7 Don't know / Not sure 8 Never 9 Refused 7.2 How many of your permanent teeth have been removed because of tooth decay or gum disease? Include teeth lost to infection, but do not include teeth lost for other reasons, such as injury or orthodontics. NOTE: If wisdom teeth are removed because of tooth decay or gum disease, they should be included in the count for lost teeth. (89) 1 1 to 5 2 6 or more but not all 3 All 8 None 7 Don't know / Not sure 9 Refused CATI note: If Q7.1 = 8 (Never) or Q 7.2 = 3 (All), go to next section. 7.3 How long has it been since you had your teeth cleaned by a dentist or dental hygienist? (90) Read only if necessary: 1 Within the past year (anytime less than 12 months ago) 2 Within the past 2 years (1 year but less than 2 years ago) 3 Within the past 5 years (2 years but less than 5 years ago) 4 5 or more years ago Do not read: 7 Don't know / Not sure 8 Never 9 Refused Section 8: Cardiovascular Disease Prevalence Now I would like to ask you some questions about cardiovascular disease. Has a doctor, nurse, or other health professional EVER told you that you had any of the following? For each, tell me "Yes," "No," or you're "Not sure." 8.1 (Ever told) you had a heart attack, also called a myocardial infarction? (91) 1 Yes 2 No 7 Don't know / Not sure 9 Refused 8.2 (Ever told) you had angina or coronary heart disease? (92) 1 Yes 2 No 7 Don't know / Not sure 9 Refused 8.3 (Ever told) you had a stroke? (93) 1 Yes 2 No 7 Don't know / Not sure 9 Refused Section 9: Asthma 9.1 Have you ever been told by a doctor, nurse, or other health professional that you had asthma? (94) 1 Yes 2 No [Go to next section] 7 Don't know / Not sure [Go to next section] 9 Refused [Go to next section] 9.2 Do you still have asthma? (95) 1 Yes 2 No 7 Don't know / Not sure 9 Refused Section 10: Disability The following questions are about health problems or impairments you may have. 10.1 Are you limited in any way in any activities because of physical, mental, or emotional problems? (96) 1 Yes 2 No 7 Don't know / Not sure 9 Refused 10.2 Do you now have any health problem that requires you to use special equipment, such as a cane, a wheelchair, a special bed, or a special telephone? (97) Include occasional use or use in certain circumstances. 1 Yes 2 No 7 Don't know / Not sure 9 Refused Section 11: Tobacco Use 11.1 Have you smoked at least 100 cigarettes in your entire life? (98) NOTE: 5 packs = 100 cigarettes 1 Yes 2 No [Go to next section] 7 Don't know / Not sure [Go to next section] 9 Refused [Go to next section] 11.2 Do you now smoke cigarettes every day, some days, or not at all? (99) 1 Every day 2 Some days 3 Not at all [Go to next section] 7 Don't know / Not sure [Go to next section] 9 Refused [Go to next section] 11.3 During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking? (100) 1 Yes 2 No 7 Don't know / Not sure 9 Refused Section 12: Demographics 12.1 What is your age? (101-102) _ _ Code age in years 0 7 Don't know / Not sure 0 9 Refused 12.2 Are you Hispanic or Latino? (103) 1 Yes 2 No 7 Don't know / Not sure 9 Refused 12.3 Which one or more of the following would you say is your race? (104-109) (Check all that apply) Please read: 1 White 2 Black or African American 3 Asian 4 Native Hawaiian or Other Pacific Islander 5 American Indian or Alaska Native Or 6 Other [specify]______________ Do not read: 8 No additional choices 7 Don't know / Not sure 9 Refused CATI note: If more than one response to Q12.3; continue. Otherwise, go to Q12.5 12.4 Which one of these groups would you say best represents your race? (110) 1 White 2 Black or African American 3 Asian 4 Native Hawaiian or Other Pacific Islander 5 American Indian or Alaska Native 6 Other [specify] __________________ Do not read: 7 Don't know / Not sure 9 Refused 12.5 Have you ever served on active duty in the United States Armed Forces, either in the regular military or in a National Guard or military reserve unit? Active duty does not include training for the Reserves or National Guard, but DOES include activation, for example, for the Persian Gulf War. (111) 1 Yes 2 No 7 Don't know / Not sure 9 Refused 12.6 Are you...? (112) Please read: 1 Married 2 Divorced 3 Widowed 4 Separated 5 Never married Or 6 A member of an unmarried couple Do not read: 9 Refused 12.7 How many children less than 18 years of age live in your household? (113-114) _ _ Number of children 8 8 None 9 9 Refused 12.8 What is the highest grade or year of school you completed? (115) Read only if necessary: 1 Never attended school or only attended kindergarten 2 Grades 1 through 8 (Elementary) 3 Grades 9 through 11 (Some high school) 4 Grade 12 or GED (High school graduate) 5 College 1 year to 3 years (Some college or technical school) 6 College 4 years or more (College graduate) Do not read: 9 Refused 12.9 Are you currently...? (116) Please read: 1 Employed for wages 2 Self-employed 3 Out of work for more than 1 year 4 Out of work for less than 1 year 5 A Homemaker 6 A Student 7 Retired Or 8 Unable to work Do not read: 9 Refused 12.10 Is your annual household income from all sources- (117-118) If respondent refuses at ANY income level, code '99' (Refused) Read only if necessary: 0 4 Less than $25,000 If "no," ask 05; if "yes," ask 03 ($20,000 to less than $25,000) 0 3 Less than $20,000 If "no," code 04; if "yes," ask 02 ($15,000 to less than $20,000) 0 2 Less than $15,000 If "no," code 03; if "yes," ask 01 ($10,000 to less than $15,000) 0 1 Less than $10,000 If "no," code 02 0 5 Less than $35,000 If "no," ask 06 ($25,000 to less than $35,000) 0 6 Less than $50,000 If "no," ask 07 ($35,000 to less than $50,000) 0 7 Less than $75,000 If "no," code 08 ($50,000 to less than $75,000) 0 8 $75,000 or more Do not read: 7 7 Don't know / Not sure 9 9 Refused 12.11 About how much do you weigh without shoes? (119-122) NOTE: If respondent answers in metrics, put "9" in column 119. Round fractions up _ _ _ _ Weight (pounds/kilograms) 7 7 7 7 Don't know / Not sure 9 9 9 9 Refused CATI note: If Q12.11 = 7777 (Don't know/Not sure) or 9999 (Refused), skip Q12.13 and Q12.14). 12.12 About how tall are you without shoes? (123-126) NOTE: If respondent answers in metrics, put "9" in column 123. Round fractions down _ _ / _ _ Height (ft / inches/meters/centimeters) 7 7 7 7 Don't know / Not sure 9 9 9 9 Refused 12.13 How much did you weigh a year ago? [If you were pregnant a year ago, how much did you weigh before your pregnancy?] CATI: If female respondent and age <46. (127-130) NOTE: If respondent answers in metrics, put "9" in column 127. Round fractions up _ _ _ _ Weight (pounds/kilograms) 7 7 7 7 Don't know / Not sure 9 9 9 9 Refused CATI note: Subtract weight one year ago from current weight. If weight is same, skip Q12.14. 12.14 Was the change between your current weight and your weight a year ago intentional? (131) 1 Yes 2 No 7 Don't know / Not sure 9 Refused 12.15 What county do you live in? (132-134) _ _ _ FIPS county code 7 7 7 Don't know / Not sure 9 9 9 Refused 12.16 What is your ZIP Code where you live? (135-139) _ _ _ _ _ ZIP Code 7 7 7 7 7 Don't know / Not sure 9 9 9 9 9 Refused 12.17 Do you have more than one telephone number in your household? Do not include cell phones or numbers that are only used by a computer or fax machine. (140) 1 Yes 2 No [Go to Q12.19] 7 Don't know / Not sure [Go to Q12.19] 9 Refused [Go to Q12.19] 12.18 How many of these telephone numbers are residential numbers? (141) _ Residential telephone numbers [6 = 6 or more] 7 Don't know / Not sure 9 Refused 12.19 During the past 12 months, has your household been without telephone service for 1 week or more? Do not include interruptions of telephone service because of weather or natural disasters. (142) 1 Yes 2 No 7 Don't know / Not sure 9 Refused 12.20 Indicate sex of respondent. Ask only if necessary. (143) 1 Male [Go to next section] 2 Female [If respondent is 45 years old or older, go to next section] 12.21 To your knowledge, are you now pregnant? (144) 1 Yes 2 No 7 Don't know / Not sure 9 Refused Section 13: Alcohol Consumption 13.1 During the past 30 days, have you had at least one drink of any alcoholic beverage such as beer, wine, a malt beverage or liquor? (145) 1 Yes 2 No [Go to next section] 7 Don't know / Not sure [Go to next section] 9 Refused [Go to next section] 13.2 During the past 30 days, how many days per week or per month did you have at least one drink of any alcoholic beverage? (146-148) 1_ _ _ Days per week 2_ _ _ Days in past 30 days 8 8 8 No drinks in past 30 days [Go to next section] 7 7 7 Don't know / Not sure 9 9 9 Refused 13.3 One drink is equivalent to a 12-ounce beer, a 5-ounce glass of wine, or a drink with one shot of liquor. During the past 30 days, on the days when you drank, about how many drinks did you drink on the average? NOTE: A 40 ounce beer would count as 3 drinks, or a cocktail drink with 2 shots would count as 2 drinks. (149-150) _ _ Number of drinks 7 7 Don't know / Not sure 9 9 Refused 13.4 Considering all types of alcoholic beverages, how many times during the past 30 days did you have X [CATI X = 5 for men, X = 4 for women] or more drinks on an occasion? (151-152) _ _ Number of times 8 8 None 7 7 Don't know / Not sure 9 9 Refused 13.5 During the past 30 days, what is the largest number of drinks you had on any occasion? (153-154) _ _ Number of drinks 7 7 Don't know / Not sure 9 9 Refused Section 14: Immunization 14.1 A flu shot is an influenza vaccine injected into your arm. During the past 12 months, have you had a flu shot? (155) 1 Yes 2 No [Go to Q14.3] 7 Don't know / Not sure [Go to Q14.3] 9 Refused [Go to Q14.3] 14.2 During what month and year did you receive your most recent flu shot? (156-161) _ _ / _ _ _ _ Month / Year 7 7 / 7 7 7 7 Don't know / Not sure 9 9 / 9 9 9 9 Refused 14.3 During the past 12 months, have you had a flu vaccine that was sprayed in your nose? The flu vaccine sprayed in the nose is also called FluMist(tm). (162) 1 Yes 2 No [Go to Q14.5] 7 Don't know / Not sure [Go to Q14.5] 9 Refused [Go to Q14.5] 14.4 During what month and year did you receive your most recent flu vaccine that was sprayed in your nose? (163-168) _ _ / _ _ _ _ Month / Year 7 7 / 7 7 7 7 Don't know / Not sure 9 9 / 9 9 9 9 Refused 14.5 A pneumonia shot or pneumococcal vaccine is usually given only once or twice in a person's lifetime and is different from the flu shot. Have you ever had a pneumonia shot? (169) 1 Yes 2 No 7 Don't know / Not sure 9 Refused Section 15: Falls If respondent is 45 years or older continue, otherwise go to next section. The next questions ask about recent falls. By a fall, we mean when a person unintentionally comes to rest on the ground or another lower level. 15.1 In the past 3 months, how many times have you fallen? (170-171) _ _ Number of times [76 = 76 or more] 8 8 None [Go to next section] 7 7 Don't know / Not sure [Go to next section] 9 9 Refused [Go to next section] 15.2 [Fill in "Did this fall (from Q15.1) cause an injury?"]. If only one fall from Q15.1 and response is "Yes" (caused an injury); code 01. If response is "No," code 88. How many of these falls caused an injury? By an injury, we mean the fall caused you to limit your regular activities for at least a day or to go see a doctor. (172-173) _ _ Number of falls [76 = 76 or more] 8 8 None [Go to next section] 7 7 Don't know / Not sure [Go to next section] 9 9 Refused [Go to next section] Section 16: Seatbelt Use 16.1 How often do you use seat belts when you drive or ride in a car? Would you say- (174) Please read: 1 Always 2 Nearly always 3 Sometimes 4 Seldom 5 Never Do not read: 7 Don't know / Not sure 8 Never drive or ride in a car 9 Refused CATI note: If Q16.1 = 8 (Never drive or ride in a car), go to Section 18; otherwise continue. Section 17: Drinking and Driving CATI note: If Q13.1 = 2 (No); go to next section. The next question is about drinking and driving. 17.1 During the past 30 days, how many times have you driven when you've had perhaps too much to drink? (175-176) _ _ Number of times 8 8 None 7 7 Don't know / Not sure 9 9 Refused Section 18: Women's Health CATI note: If respondent is male, go to the next section. The next questions are about breast and cervical cancer. 18.1 A mammogram is an x-ray of each breast to look for breast cancer. Have you ever had a mammogram? (177) 1 Yes 2 No [Go to Q18.3] 7 Don't know / Not sure [Go to Q18.3] 9 Refused [Go to Q18.3] 18.2 How long has it been since you had your last mammogram? (178) Read only if necessary: 1 Within the past year (anytime less than 12 months ago) 2 Within the past 2 years (1 year but less than 2 years ago) 3 Within the past 3 years (2 years but less than 3 years ago) 4 Within the past 5 years (3 years but less than 5 years ago) 5 5 or more years ago Do not read: 7 Don't know / Not sure 9 Refused 18.3 A clinical breast exam is when a doctor, nurse, or other health professional feels the breasts for lumps. Have you ever had a clinical breast exam? (179) 1 Yes 2 No [Go to Q18.5] 7 Don't know / Not sure [Go to Q18.5] 9 Refused [Go to Q18.5] 18.4 How long has it been since your last breast exam? (180) Read only if necessary: 1 Within the past year (anytime less than 12 months ago) 2 Within the past 2 years (1 year but less than 2 years ago) 3 Within the past 3 years (2 years but less than 3 years ago) 4 Within the past 5 years (3 years but less than 5 years ago) 5 5 or more years ago Do not read: 7 Don't know / Not sure 9 Refused 18.5 A Pap test is a test for cancer of the cervix. Have you ever had a Pap test? (181) 1 Yes 2 No [Go to Q18.7] 7 Don't know / Not sure [Go to Q18.7] 9 Refused [Go to Q18.7] 18.6 How long has it been since you had your last Pap test? (182) Read only if necessary: 1 Within the past year (anytime less than 12 months ago) 2 Within the past 2 years (1 year but less than 2 years ago) 3 Within the past 3 years (2 years but less than 3 years ago) 4 Within the past 5 years (3 years but less than 5 years ago) 5 5 or more years ago Do not read: 7 Don't know / Not sure 9 Refused CATI note: If response to Core Q12.21 = 1 (is pregnant); then go to next section. 18.7 Have you had a hysterectomy? (183) Read only if necessary: A hysterectomy is an operation to remove the uterus (womb). 1 Yes 2 No 7 Don't know / Not sure 9 Refused Section 19: Prostate Cancer Screening CATI note: If respondent is <39 years of age, or is female, go to next section. Now, I will ask you some questions about prostate cancer screening. 19.1 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? (184) 1 Yes 2 No [Go to Q19.3] 7 Don't Know / Not sure [Go to Q19.3] 9 Refused [Go to Q19.3] 19.2 How long has it been since you had your last PSA test? (185) Read only if necessary: 1 Within the past year (anytime less than 12 months ago) 2 Within the past 2 years (1 year but less than 2 years) 3 Within the past 3 years (2 years but less than 3 years) 4 Within the past 5 years (3 years but less than 5 years) 5 5 or more years ago Do not read: 7 Don't know / Not sure 9 Refused 19.3 A digital rectal exam is an exam in which a doctor, nurse, or other health professional places a gloved finger into the rectum to feel the size, shape, and hardness of the prostate gland. Have you ever had a digital rectal exam? (186) 1 Yes 2 No [Go to Q19.5] 7 Don't know / Not sure [Go to Q19.5] 9 Refused [Go to Q19.5] 19.4 How long has it been since your last digital rectal exam? (187) Read only if necessary: 1 Within the past year (anytime less than 12 months ago) 2 Within the past 2 years (1 year but less than 2 years) 3 Within the past 3 years (2 years but less than 3 years) 4 Within the past 5 years (3 years but less than 5 years) 5 5 or more years ago Do not read: 7 Don't know / Not sure 9 Refused 19.5 Have you ever been told by a doctor, nurse, or other health professional that you had prostate cancer? (188) 1 Yes 2 No 7 Don't know / Not sure 9 Refused Section 20: Colorectal Cancer Screening CATI note: If respondent is < 49 years of age, go to next section. 20.1 A blood stool test is a test that may use a special kit at home to determine whether the stool contains blood. Have you ever had this test using a home kit? (189) 1 Yes 2 No [Go to Q20.3] 7 Don't know / Not sure [Go to Q20.3] 9 Refused [Go to Q20.3] 20.2 How long has it been since you had your last blood stool test using a home kit? (190) Read only if necessary: 1 Within the past year (anytime less than 12 months ago) 2 Within the past 2 years (1 year but less than 2 years ago) 3 Within the past 5 years (2 years but less than 5 years ago) 4 5 or more years ago Do not read: 7 Don't know / Not sure 9 Refused 20.3 Sigmoidoscopy and colonoscopy are exams in which a tube is inserted in the rectum to view the colon for signs of cancer or other health problems. Have you ever had either of these exams? (191) 1 Yes 2 No [Go to next section] 7 Don't know / Not sure [Go to next section] 9 Refused [Go to next section] 20.4 For a SIGMOIDOSCOPY, a flexible tube is inserted into the rectum to look for problems. A COLONOSCOPY is similar, but uses a longer tube, and you are usually given medication through a needle in your arm to make you sleepy and told to have someone else drive you home after the test. Was your MOST RECENT exam a sigmoidoscopy or a colonoscopy? (192) 1 Sigmoidoscopy 2 Colonoscopy 7 Don't know / Not sure 9 Refused 20.5 How long has it been since you had your last sigmoidoscopy or colonoscopy? (193) Read only if necessary: 1 Within the past year (anytime less than 12 months ago) 2 Within the past 2 years (1 year but less than 2 years ago) 3 Within the past 5 years (2 years but less than 5 years ago) 4 Within the past 10 years (5 years but less than 10 years ago) 5 10 or more years ago Do not read: 7 Don't know / Not sure 9 Refused Section 21: HIV/AIDS CATI note: If respondent is 65 years old or older, go to next section. The next few questions are about the national health problem of HIV, the virus that causes AIDS. Please remember that your answers are strictly confidential and that you don't have to answer every question if you do not want to. Although we will ask you about testing, we will not ask you about the results of any test you may have had. 21.1 Have you ever been tested for HIV? Do not count tests you may have had as part of a blood donation. Include testing fluid from your mouth. (194) 1 Yes 2 No [Go to Q21.5] 7 Don't know / Not sure [Go to Q21.5] 9 Refused [Go to Q21.5] 21.2 Not including blood donations, in what month and year was your last HIV test? (195-200) NOTE: If response is before January 1985, code "Don't know." CATI INSTRUCTION: If the respondent remembers the year but cannot remember the month, code the first two digits 77, and the last four digits for the year. _ _ /_ _ _ _ Code month and year 7 7/ 7 7 7 7 Don't know / Not sure 9 9/ 9 9 9 9 Refused 21.3 Where did you have your last HIV test - at a private doctor or HMO office, at counseling and testing site, at a hospital, at a clinic, in a jail or prison, at a drug treatment facility, at home, or somewhere else? (201-202) 0 1 Private doctor or HMO office 0 2 Counseling and testing site 0 3 Hospital 0 4 Clinic 0 5 Jail or prison (or other correctional facility) 0 6 Drug treatment facility 0 7 At home 0 8 Somewhere else 7 7 Don't know / Not sure 9 9 Refused CATI note: Ask Q21.4; if Q21.2 = within last 12 months. Otherwise, go to Q21.5. 21.4 Was it a rapid test where you could get your results within a couple of hours? (203) 1 Yes 2 No 7 Don't know / Not sure 9 Refused 21.5 I'm going to read you a list. When I'm done, please tell me if any of the situations apply to you. You do not need to tell me which one. You have used intravenous drugs in the past year. You have been treated for a sexually transmitted or venereal disease in the past year. You have given or received money or drugs in exchange for sex in the past year. You had anal sex without a condom in the past year. Do any of these situations apply to you? (204) 1 Yes 2 No 7 Don't know / Not sure 9 Refused Section 22: Emotional Support and Life Satisfaction The next two questions are about emotional support and your satisfaction with life. 22.1 How often do you get the social and emotional support you need? INTERVIEWER NOTE: If asked, say "please include support from any source." (205) Please read: 1 Always 2 Usually 3 Sometimes 4 Rarely 5 Never Do not read: 7 Don't know / Not sure 9 Refused 22.2 In general, how satisfied are you with your life? (206) Please read: 1 Very satisfied 2 Satisfied 3 Dissatisfied 4 Very dissatisfied Do not read: 7 Don't know / Not sure 9 Refused Transition to modules and/or state-added questions. Optional Modules Module 1: Pre-Diabetes NOTE: Only asked of those not responding "Yes" (code = 1) to Core Q6.1 (Diabetes awareness question). 1. Have you had a test for high blood sugar or diabetes within the past three years? (227) 1 Yes 2 No 7 Don't know / Not sure 9 Refused CATI note: If Core Q6.1 = 4 (No, pre-diabetes or borderline diabetes); answer Q2 "Yes" (code = 1). 2. Have you ever been told by a doctor or other health professional that you have pre- diabetes or borderline diabetes? (228) 1 Yes 2 No 7 Don't know / Not sure 9 Refused Module 2: Diabetes To be asked following Core Q6.1; if response is "Yes" (code = 1) 1. How old were you when you were told you have diabetes? (229-230) _ _ Code age in years [97 = 97 and older] 9 8 Don't know / Not sure 9 9 Refused 2. Are you now taking insulin? (231) 1 Yes 2 No 9 Refused 3. About how often do you check your blood for glucose or sugar? Include times when checked by a family member or friend, but do NOT include times when checked by a health professional. (232-234) 1 _ _ Times per day 2 _ _ Times per week 3 _ _ Times per month 4 _ _ Times per year 8 8 8 Never 7 7 7 Don't know / Not sure 9 9 9 Refused 4. About how often do you check your feet for any sores or irritations? Include times when checked by a family member or friend, but do NOT include times when checked by a health professional. (235-237) 1 _ _ Times per day 2 _ _ Times per week 3 _ _ Times per month 4 _ _ Times per year 5 5 5 No feet 8 8 8 Never 7 7 7 Don't know / Not sure 9 9 9 Refused 5. About how many times in the past 12 months have you seen a doctor, nurse, or other health professional for your diabetes? (238-239) _ _ Number of times [76 = 76 or more] 8 8 None 7 7 Don't know / Not sure 9 9 Refused 6. A test for "A one C" measures the average level of blood sugar over the past three months. About how many times in the past 12 months has a doctor, nurse, or other health professional checked you for "A one C"? (240-241) _ _ Number of times [76 = 76 or more] 8 8 None 9 8 Never heard of "A one C" test 7 7 Don't know / Not sure 9 9 Refused CATI note: If Q4 = 555 (No feet), go to Q8. 7. About how many times in the past 12 months has a health professional checked your feet for any sores or irritations? (242-243) _ _ Number of times [76 = 76 or more] 8 8 None 7 7 Don't know / Not sure 9 9 Refused 8. When was the last time you had an eye exam in which the pupils were dilated? This would have made you temporarily sensitive to bright light. (244) Read only if necessary: 1 Within the past month (anytime less than 1 month ago) 2 Within the past year (1 month but less than 12 months ago) 3 Within the past 2 years (1 year but less than 2 years ago) 4 2 or more years ago Do not read: 7 Don't know / Not sure 8 Never 9 Refused 9. Has a doctor ever told you that diabetes has affected your eyes or that you had retinopathy? (245) 1 Yes 2 No 7 Don't know / Not sure 9 Refused 10. Have you ever taken a course or class in how to manage your diabetes yourself? (246) 1 Yes 2 No 7 Don't know / Not sure 9 Refused Module 6: Binge Drinking Previously, you answered that you drank [5 or more for men, 4 or more for women] alcoholic beverages on at least one occasion in the past 30 days. The next questions are about the most recent occasion when this happened. For these questions, one drink equals 12 ounces of beer, 5 ounces of wine, or one and one-half ounces (one shot) of liquor. So, a 40-ounce beer would count as 3 drinks, or a cocktail drink with 2 shots would count as 2 drinks. INTERVIEWER NOTE: If asked, "occasion" means in a row or within a few hours. 1. During the most recent occasion when you had [5 or more for men, 4 or more for women] alcoholic beverages, about how many beers, including malt liquor, did you drink? (269-270) _ _ Number 8 8 None 7 7 Don't know / Not sure 9 9 Refused 2. During the same occasion, about how many glasses of wine did you drink? (271-272) _ _ Number 8 8 None 7 7 Don't know / Not sure 9 9 Refused 3. During the same occasion, about how many drinks of liquor, including cocktails, did you have? (273-274) _ _ Number 8 8 None 7 7 Don't know / Not sure 9 9 Refused 4. During the same occasion, about how many other pre-mixed, flavored drinks did you have? By that, we mean drinks such as hard lemonade, wine coolers, or Smirnoff Ice. (275-276) _ _ Number 8 8 None 7 7 Don't know / Not sure 9 9 Refused 5. During this most recent occasion, where were you when you did most of your drinking? (277) Read only if necessary: 1 At your home, for example, your house, apartment, or dorm room 2 At another person's home 3 At a restaurant or banquet hall 4 At a bar or club 5 At a public place, such as at a park, concert, or sporting event Do not read: 6 Other 7 Don't know / Not sure 9 Refused 6. Did you drive a motor vehicle such as a car, truck, or motorcycle during or within a couple of hours after this occasion? INTERVIEWER NOTE: For those with concerns about this question, answering "Yes" is not meant to imply they were drunk driving or breaking the law. (278) 1 Yes 2 No 7 Don't know / Not sure 9 Refused CATI note: Ask Q7 only if response to Q5 = 3 (At a restaurant or banquet hall) or 4 (At a bar or club). Otherwise, go to next module. 7. During this most recent occasion, approximately how much did you pay for the alcohol which you drank? INTERVIEWER NOTE: If anyone asks, they do not need to include the amount spent on tips. (279-281) _ _ _ Total amount 8 8 8 Paid nothing - all drinks free or paid for by others 7 7 7 Don't know / Not sure 9 9 9 Refused Module 7: Other Tobacco Products Now, I would like to ask you questions about your use of tobacco products other than cigarettes. 1. Have you ever used or tried any smokeless tobacco products such as chewing tobacco, snuff, or snus? (Snus rhymes with goose). (282) NOTE: Snus (Swedish for snuff) is a moist smokeless tobacco, usually sold in small pouches that is placed under the lip against the gum. 1 Yes 2 No [Go to Q3] 7 Don't know / Not sure [Go to Q3] 9 Refused [Go to Q3] 2. Do you currently use chewing tobacco, snuff, or snus every day, some days, or not at all? (283) 1 Every day 2 Some days 3 Not at all 7 Don't know / Not sure 9 Refused 3. Do you currently use any tobacco products other than cigarettes, cigars, pipes, bidis, kreteks, or any of the previously mentioned tobacco products? NOTE: Bidis are small, brown, hand-rolled cigarettes from India and other southeast Asian countries. Kreteks are clove cigarettes made in Indonesia that contain clove extract and tobacco. (284) 1 Yes 2 No 7 Don't know / Not sure 9 Refused [ADD STATE QUESTIONS ON TOBACCO USE HERE] [PROGRAMMER NOTE: If answers to M7 Q1-3 include "yes" answers, ask the first two state-added questions that follow. Otherwise, skip to state-added tobacco questions 3 and 4.] Module 10: Adult Human Papilloma Virus (HPV) CATI note: To be asked of females between the ages of 18 and 49 years; otherwise, go to next module. NOTE: Human Papilloma Virus (Human Pap*uh*loh*muh Virus); Gardasil (Gar*duh* seel) 1. A vaccine to prevent the human papilloma virus or HPV infection is available and is called cervical cancer vaccine, HPV shot, or GARDASIL(r). Have you EVER had the HPV vaccination? (309) 1 Yes 2 No [Go to next module] 3 Doctor refused when asked [Go to next module] 7 Don't know / Not sure [Go to next module] 9 Refused [Go to next module] INSTRUCTION NOTE: This question will replace Q1; when Cervarix(r) is licensed in 2008. (Alternative) 1. A vaccine to prevent the human papilloma virus or HPV infection is available and is called cervical cancer vaccine, HPV shot, GARDASIL(r), or Cervarix(r). Have you EVER had the HPV vaccination? (309) 1 Yes 2 No [Go to next module] 3 Doctor refused when asked [Go to next module] 7 Don't know / Not sure [Go to next module] 9 Refused [Go to next module] 2. How many HPV shots did you receive? (310-311) _ _ Number of shots 0 3 All shots 7 7 Don't know / Not sure 9 9 Refused Module 15: Random Child Selection CATI note: If Core Q12.7 = 88, or 99 (No children under age 18 in the household, or Refused), go to next module. If Core Q12.7 = 1, Interviewer please read: "Previously, you indicated there was one child age 17 or younger in your household. I would like to ask you some questions about that child." [Go to Q1] If Core Q12.7 is >1 and Core Q12.7 does not equal 88 or 99, Interviewer please read: "Previously, you indicated there were [number] children age 17 or younger in your household. Think about those [number] children in order of their birth, from oldest to youngest. The oldest child is the first child and the youngest child is the last." Please include children with the same birth date, including twins, in the order of their birth. CATI INSTRUCTION: RANDOMLY SELECT ONE OF THE CHILDREN. This is the "Xth" child. Please substitute "Xth" child's number in all questions below. INTERVIEWER PLEASE READ: I have some additional questions about one specific child. The child I will be referring to is the "Xth" [CATI: please fill in correct number] child in your household. All following questions about children will be about the "Xth" [CATI: please fill in] child." 1. What is the birth month and year of the "Xth" child? (366-371) _ _ /_ _ _ _ Code month and year 7 7/ 7 7 7 7 Don't know / Not sure 9 9/ 9 9 9 9 Refused CATI INSTRUCTION: Calculate the child's age in months (CHLDAGE1=0 to 216) and also in years (CHLDAGE2=0 to 17) based on the interview date and the birth month and year using a value of 15 for the birth day. If the selected child is < 12 months old enter the calculated months in CHLDAGE1 and 0 in CHLDAGE2. If the child is > 12 months enter the calculated months in CHLDAGE1 and set CHLDAGE2=Truncate (CHLDAGE1/12). 2. Is the child a boy or a girl? (372) 1 Boy 2 Girl 9 Refused 3. Is the child Hispanic or Latino? (373) 1 Yes 2 No 7 Don't know / Not sure 9 Refused 4. Which one or more of the following would you say is the race of the child? (374-379) [Check all that apply] Please read: 1 White 2 Black or African American 3 Asian 4 Native Hawaiian or Other Pacific Islander 5 American Indian, Alaska Native Or 6 Other [specify] ____________________ Do not read: 8 No additional choices 7 Don't know / Not sure 9 Refused CATI note: If more than one response to Q4, continue. Otherwise, go to Q6. 5. Which one of these groups would you say best represents the child's race? (380) 1 White 2 Black or African American 3 Asian 4 Native Hawaiian or Other Pacific Islander 5 American Indian, Alaska Native 6 Other 7 Don't know / Not sure 9 Refused 6. How are you related to the child? (381) Please read: 1 Parent (include biologic, step, or adoptive parent) 2 Grandparent 3 Foster parent or guardian 4 Sibling (include biologic, step, and adoptive sibling) 5 Other relative 6 Not related in any way Do not read: 7 Don't know / Not sure 9 Refused Module 17: Child Human Papilloma Virus (HPV) If selected child is female between ages 9 and 17 years; continue. Otherwise, go to next module. NOTE: Human Papilloma Virus (Human Pap*uh*loh*muh Virus); Gardasil(r) (Gar*duh* seel) I have two additional questions about a vaccination the selected child may have had. 1. A vaccine to prevent the human papilloma virus or HPV infection is available and is called cervical cancer vaccine, HPV shot, or GARDASIL(r). Has this child EVER had the HPV vaccination? (384) 1 Yes 2 No [Go to next module] 3 Doctor refused when asked [Go to next module] 7 Don't know / Not sure [Go to next module] 9 Refused [Go to next module] INSTRUCTION NOTE: This question will replace Q1; when Cervarix(r) is licensed in 2008. (Alternative) 1. A vaccine to prevent the human papilloma virus or HPV infection is available and is called cervical cancer vaccine, HPV shot, GARDASIL(r), or Cervarix(r). Have you EVER had the HPV vaccination? (384) 1 Yes 2 No [Go to next module] 3 Doctor refused when asked [Go to next module] 7 Don't know / Not sure [Go to next module] 9 Refused [Go to next module] 2. How many HPV shots did she receive? (385-386) _ _ Number of shots 0 3 All shots 7 7 Don't know / Not sure 9 9 Refused CATI Note: State-added questions begin in column 401. Closing statement Please read: That is my last question. Everyone's answers will be combined to give us information about the health practices of people in this state. Thank you very much for your time and cooperation. STATE-ADDED QUESTIONS FOR 2008 BRFSS QUESTIONNAIRE - Delaware Date 11/01/2007 Columns (beginning with 401; not To exceed 650) Question Response Categories (Code = Response) (401) You indicated that you have a health problem or impairment that limits your activities. How would you generally describe this disability? Is it... (INTERVIEWER: Please select all that apply) 1. A visual problem 2. A hearing problem 3. Other physical problem (due to chronic illness, accident, etc.) 4. An emotional problem (such as depression, anxiety or a psychiatric illness) 5. Or other type of disability (enter 'other') DO NOT READ 7. Don't know/Not sure 9. Refused (402) [ASK IMMEDIATELY AFTER MODULE 7: OTHER TOBACCO PRODUCTS] Do you currently smoke cigarillos or "little cigars" every day, some days, or not at all? [Read if necessary: Little cigars look like cigarettes but are wrapped in tobacco leaves.] 1. Every day 2. Some day 3. Not at all DO NOT READ 7. Don't know/Not sure 9. Refused 403-404 On how many of the past 7 days did anyone smoke in your home while you were there? __ Number of days (1-7) 55. I was not home in the past 7 days 88. None DO NOT READ 77. Don't know/Not sure 99. Refused (405) Which statement best describes the rules about smoking inside your home? DO NOT READ UNLESS ASKED Do not include decks, garages, or porches. 1. Smoking is not allowed anywhere inside my home. 2. Smoking is allowed in some places or at some times 3. Smoking is allowed anywhere inside my home. OR 4. There are no rules about smoking in my home. DO NOT READ 7. Don't know/Not sure 9. Refused (406) [FINAL FOUR QUESTIONS ON SURVEY] The next few questions are about pregnancy and ways to prevent pregnancy. [IF RESPONDENT IS FEMALE AND 45 YEARS OF AGE OR OLDER, OR PREGNANT, OR MALE 60 YEARS OR OLDER, GO TO NEXT MODULE.] Are you or your [if female, insert husband/partner; if male, insert wife/partner] doing anything now to keep from getting pregnant? Some things people do to keep from getting pregnant include the birth control pill, diaphragm, condoms, natural methods, and having their tubes tied or having a vasectomy. [IF MULTIPLE PARTNERS, CONSIDER USUAL METHOD.] 1. Yes 2. No Go to 409 3. No partner/Not sexually active [Go to 409] DO NOT READ 7. Don't know/Not sure [Go to 409] 9. Refused [Go to 409] (407-408) What are or you or your partner/spouse doing now to keep you/her from getting pregnant? [IF MORE THAN ONE IS MENTIONED, PROBE FOR THE PRIMARY METHOD USED.] READ ONLY IF NECESSARY 01 Tubes tied (sterilization) 02 Vasectomy (sterilization) 03 BC Pill 04 Condoms 05 Foam, jelly, cream 06 Diaphragm 07 Norplant 08 IUD 09 Shots (Depo-prevera) 10 Withdrawal 11 Rhythm/natural 12 No partner/Not sexually active 13 Other methods 77 Don't know/Not sure 99 Refused (409-410) [Females] What is your main reason for not doing anything to keep you from getting pregnant? [Males] What is your main reason for not doing anything to keep your partner from getting pregnant? READ ONLY IF NECESSARY 01 Not sexually active/No partner 02 Didn't think was going to have sex/no regular partner 03 Want a pregnancy 04 You/Partner don't want to use BC 05 You/Partner don't like BC / fear side effects 06 Can't afford BC 07 Lapse in use of a method 08 Sterilization (tubes tied / vasectomy) 09 Hysterectomy 10 Too old 11 Currently breast feeding / Just had baby 12 Pregnant now 13 Other 77 Don't know/Not sure 99 Refused (411-412) [ASK OF WOMEN ONLY] Where is your usual source of services for female health concerns, such as family planning, annual exams, breast exams, tests for sexually transmitted diseases, or other female health concerns? Would you say 01 A family planning clinic [e.g. Planned Parenthood] 02 A Public Health/health department clinic 03 A community health center (e.g. FQHCs) 04 A private gynecologist 05 A family physician 06 Another source 77 Don't know/Not sure 99 Refused q:\brfss\2008\documents\stlay08.xx.doc