TRACKS Male Nutrition Education Needs Assessment Survey Questions
Final Version 5-25-11
11-5200
INTRO. Hello, may I speak to [male’s name from contact list]? [If not available ask if there is a good time to
call to reach this person.]
My name is__________ from ____________. We are conducting a survey for Penn State University to learn
more about nutrition interests and behaviors of males. If you are eligible to participate, I will ask you some
questions over the phone, which may take up to 25 minutes. Afterwards you will receive a $15 Wal-Mart gift
card to thank you for your time. Your responses to this survey will not affect any benefits you receive, and
responses will be kept confidential.
Are you interested in continuing?
NoEnd interview. (Ok, thanks.)
Yes, but need to schedule another time for callSchedule follow up call
Yes, and have time nowProceed with screening questions.
Screening Questions:
SC1. First, I’m going to ask you some questions to see if you qualify for the study.
Can you understand and speak English fluently?
Yes - Continue
No – [IF NO, END SURVEY, TERM1.]
TERM1. I’m sorry. We need participants who are able to understand and speak English for this study. Thank
you very much for your time.
SC2. Do you ever take care of children—your own or others’?
Yes - Continue
No – TERM2.
TERM2. I’m sorry, the fact that you don’t take care of children means you don’t qualify for this study. Thank
you very much for your time.
SC3.
How old are you? _______ [IF OUTSIDE 18-59 AGE RANGE, END SURVEY, TERM3;
OTHERWISE CONTINUE WITH VERBAL CONSENT SCRIPT.]
TERM3. I’m sorry you won’t qualify for our study. We have a specific age range for the survey. Thank you
very much for your time.
TRACKS Male Needs Assessment Verbal Consent Script (to be read aloud by
interviewer)
CONSENT. Before we begin, I’d like to share a little more information about this Penn State research study so you can
decide whether you want to participate. The title of the study is TRACKS Male Needs Assessment and the purpose is to
learn more about nutrition interests and behaviors of males. You will be asked to answer 43 questions, which may take
up to 25 minutes. Your participation is voluntary, you may stop at any time, and you may choose not to answer specific
questions. Any information you share will remain confidential, and your name or other identifiable information will not
be recorded with your responses. You must be 18 years of age or older to participate. For your participation, you will
receive a $15 Wal-Mart gift card for your time. Do you agree to participate?
NO OK, thank you for your consideration. End call [TERMNO]
YES First of all, thank you for your consent to participate in this research.
TERMNO. Thank you for your time. Have a nice evening.
QUEST. Do you have any questions before we begin?
No [GO TO PRN]
Yes [GO TO QUESTY]
QUESTY [OPEN END] (write question in the space below, CLICK CONTINUE)
[In case the participant has questions, schedule a convenient time to call the participant back and end interview.
Explain that the PR will call them to answer any questions they may have.]
QUESTCB. [READ IF RESPONDENT HAS QUESTIONS TO BE ANSWERED BY PR] The Primary Researcher will give
you a call to answer all of your questions, then we would like to call you back after that. When would be a convenient time
for you? [CB for 3 days later] ||[CONTINUE TO NEXT SCREEN FIRST TO INTERRUPT INTERVIEW] [Barbara Lohse,
814-865-5169]
PRN. [READ TO EVERYONE] Would you like to write down the primary researcher’s name and telephone number in
case you have questions about the research following the telephone interview? I’ll be happy to wait for you to gather your
writing materials.
[When participant is ready, provide the following information.]
The primary researcher’s name is Barbara Lohse (pronounced “Low Say”). You can reach her by phone at 814865-5169, or by e-mail: lohseb@psu.edu
[Continue] -- Are you ready to begin the interview? OK Great! [SKIP TO Q1]
[Call Back] – Interrupt Interview
SURVEY QUESTIONS
1. Describe your level of involvement in taking care of children.
(open ended, but include checkboxes to code responses)
a.
b.
c.
d.
e.
Child/Children at home or who live away, but responder has primary or significant caregiver duties
Cares frequently (several days a week, every weekend, etc) for children who live away
Cares occasionally (several times a month) for children who live away
Infrequently (less than once a month)
Other: (specify)
2. For the child or children you refer to in the previous question, how many are:
2A. [TO BE ASKED IMMEDIATELY AFTER Q2 if >0] Do you care for those children full-time or part-time?
Q2 #
Children
cared for
Q2A_FT #
Children
cared for FT
Q2A_PT.
Children
cared for PT
a. 5 years or younger?
b. between the ages of 6 and 10?
c. between the ages of 11 and 18?
3. Are you the major decision maker regarding household food and shopping? (Yes, No)
4. Do you prepare meals or snacks for children? (This may be for children who live with you or for other children
who spend time with you.) (Yes, No)
EATING. I’m going to read you some statements that may describe how you think, do, or feel about your eating. Please
use a scale of Always, Often, Sometimes, Rarely, or Never. The first one is…[READ ITEM BELOW] Would you say Always,
Often, Sometimes, Rarely, or Never [PROGRAMMER NOTE: Placement of questions 5-20 should be randomly
alternated between current placement and at end of survey. However, do not randomize the order of questions 5-20]
NOTE: WEBSITE VIEWERS CONTACT Barbara Lohse (lohseb@psu.edu) for permission to use the About Your Eating, i.e.
items 5 – 20.
5. I am relaxed about eating.
6. I am comfortable about eating enough.
A=4
O=3
S=2
R=1
N=0
A
O
S
R
N
7. I have regular meals.
A
O
S
R
N
8. I feel it is okay to eat food that I like.
A
O
S
R
N
9. I experiment with new food and learn to like it.
A
O
S
R
N
10. If the situation demands, I can “make do” by eating food I
don’t much care for.
A
O
S
R
N
11. I eat a wide variety of foods.
A
O
S
R
N
12. I am comfortable with my enjoyment of food and eating.
A
O
S
R
N
13. I trust myself to eat enough for me.
A
O
S
R
N
14. I eat as much as I am hungry for.
A
O
S
R
N
15. I tune in to food and pay attention to eating.
A
O
S
R
N
16. I make time to eat.
A
O
S
R
N
17. I eat until I feel satisfied.
A
O
S
R
N
18. I enjoy food and eating.
A
O
S
R
N
19. I consider what is good for me when I eat.
A
O
S
R
N
20. I plan for feeding myself.
A
O
S
R
N
21. What nutrition topics are you interested in learning about? (Allow open-ended response.)
21_1. Now, I’m going to read a list of topics and want you to indicate yes or no to each one. Any level of
interest means yes. [YES OR NO TO EACH]
a. How to Eat more healthy foods
b. What foods are best for kids
c. How to cook
d. Keeping foods safe to eat
e. How to manage money for food
f. Shopping for food
g. Reading labels
h. Meal planning
i. Easy to use recipes
j. Weight loss
k. Physical Activity
l. How to eat for a specific health problem [IF YES, ASK 21_LYES, Which health problem?]
21_LYES. [if 21_L=yes] You mentioned yes to eating for a specific health problem. Which health problem were
you thinking of? [OPEN END]
22. Which of the following has the greatest influence on what foods you eat? [READ LIST; SELECT ONE]
m. Taste
n. Convenience
o. Cost
p. The food’s nutritional value or how healthy it is
q. Or something else? (Specify)
23. What keeps you from eating healthy foods? [DO NOT READ]
a. Don’t like the taste
b. Not enough money to buy food
c. Too hard to get to the store/store is too far away
d. The types of food that we like are not available
e. Health problems prevent me from cooking/purchasing food
f. Not enough time to cook or buy food
g. Don’t know what types of food are good for me
h. My family
i. I don’t choose what foods are served
j. Other (specify)
24. How often do you go online? Would you say…[READ LIST]
a.
b.
c.
d.
e.
Daily
A few times a week
Once a week
Less than once/week
Never—[SKIP TO Q28]
25. [Apply skip logic so this question is asked of respondents answering anything other than Never to previous
question] When you go online, how often do you use Facebook? [READ LIST]
a.
b.
c.
d.
e.
Daily
A few times a week
Once a week
Less than once/week
Never
26. Do you use the internet at…? [READ LIST; check all that apply]
a. Home
b. Library
c. Use a cell phone
d. Or some other way (specify)
27. How likely is it that you would go online to learn something about health or nutrition? Would you say…[READ
LIST] (5 pt response scale)
a. Very likely
b. Somewhat likely
c. Neither likely nor unlikely
d. Somewhat unlikely
e. or Not at all likely
28. Do you have a cell phone?
Yes
No – [SKIP TO Q32]
29. [If Q28 = yes] Do you have a text message plan? Yes/No
Yes
No – [SKIP TO Q32]
30. [If Q28 = yes] Would you be interested in receiving text messages on nutrition related topics?
Yes
No – [SKIP TO Q32]
31. [If Q28 = yes] How frequently would you like to receive these text messages? Would you say…[READ LIST]
(5 pt scale)
a. A few times a week
b. Once a week
c. Twice a month
d. Once a month
e. Every other month
32. Several methods can be used to learn about nutrition. Please answer with a yes or no to indicate which of
the following would you be likely to participate in.” [READ LIST a-g] [READ LIST]
a.
b.
c.
d.
e.
f.
g.
h.
A one-time group class
A series of group classes
One-on-one time with an educator
Newsletter or other print material
Online lessons or information
Text messages
Podcasts
Are there other ways you would like to learn about nutrition? (specify)
33. A household is defined as people who live under the same roof and eat meals together. Who does your
household consist of? [DO NOT READ LIST. IF RESPONDENT SEEMS TO HAVE DIFFICULTY: Do children live
with you full time or part time? Are you a single parent? Are there other extended family members such
as grandparents, cousins, or uncles who live with you?] [SELECT ALL THAT APPLY]
a.
b.
c.
d.
e.
f.
Couple, with children
Couple, without children
Single, with children
Single, without children
Extended family (e.g. grandparents, cousins, uncles, aunts, nephews, nieces)
Other (specify)
34. What is your employment status? Are you… [READ LIST]
a. Employed full-time
b. Employed part-time
c. Currently not working but actively looking for employment
d. House-husband/Stay-at-home Dad
e. Student
f. Disabled
g. Retired
h. Other (specify)
35. What is your education level?[READ LIST]
a. Some high school
b. High school graduate/GED
c. Some college
d. 2 year college graduate
e. 4 year college graduate
36. Did you or are you currently serving in the military? (Yes, No)
37. Which of the following race/ethnicity categories do you most identify with? [READ LIST]
a. White/Non-Hispanic
b. White/Hispanic or Latino
c. Black or African American/Non-Hispanic
d. Black or African American/Hispanic or Latino
e. Asian
f. Native American or Alaska Native
g. Hawaiian Native or Pacific Islander
h. Multi-racial
38. How often do you worry about having enough money for food? Would you say…[READ LIST]
a. Always
b. Often
c. Sometimes
d. Rarely
e. Never
39. Have you participated in any of the following community food programs in the past 12 months? [YES or NO
TO EACH]
a. Food Pantries
b. Food Banks
c. Supplemental Nutrition Assistance Program (Food Stamps)
d. WIC
40. On a scale of 1 to 5, with 5 representing excellent health and 1 representing major health problems, how
would you rate your current health?
41. I’m going to read a list of foods to you. For each food item, tell me yes or no if that food was available in your
home during the past week. I’m referring to the food in any form, e.g. fresh, frozen, canned, dried, raw, or
cooked. [SELECT YES OR NO FOR EACH FOOD]
a. Bananas
b. Apples
c. Grapes
d. Carrots
e. Potato chips, nacho chips, or corn chips
f. Regular soft drinks or sodas
g. Diet soft drinks or sodas
h. Regular whole or 2% milk
i. 1% or skim milk
42. [ONLY SHOW FOODS CODED AS NO AT Q41. IF ALL OF Q41 = YES, SKIP TO Q43.] Okay, now you just told me
that some of these foods were not available in your home. Were [READ FOODS LISTED BELOW] available at
the stores where you shop for food? [YES or NO TO EACH]
a. Bananas
b. Apples
c. Grapes
d. Carrots
e. Potato chips, nacho chips, or corn chips
f. Regular soft drinks or sodas
g. Diet soft drinks or sodas
h. Regular whole or 2% milk
i. 1% or skim milk
43. How satisfied are you with your current weight? Would you say…[READ LIST] ( 5 point scale response)
1) Very satisfied
2) Satisfied
3) Neutral
4) Unsatisfied
5) Very unsatisfied
VERIFY1. Those are all the questions I have. I just need to verify your name and address so that we may mail your $15
Wal-Mart gift card to you. [VERIFY NAME, MAILING ADDRESS. MAKE CORRECTIONS IF NEEDED]
VERIFY2. Would you be interested in participating in future studies?
YES
NO
If yes, record an indicator in data file. Ask for email address. If they have one, record it in the contact file.
END. Thanks for your participation in this survey. You will receive your $15 Wal-Mart gift card by mail in about 6 weeks.
Have a nice evening.