Assessment of Health Attitudes and Behaviors of Michigan Citizens

Assessment of Health Attitudes and Behaviors of Michigan Citizens

The completed responses of this survey tool will be used for planning and evaluation purposes only. Corporate reports may be generated; however, no individual data will be distributed or made available to individuals or corporations. Please answer each question to the best of your ability. You may leave a question blank, however, the more you answer the more complete the data set will be for determining needs and future programs. Thank you for your help!

Section 1: Activity Options
These questions ask your opinions about yourself and your activities.

1. Which indicates how you currently feel about your level of health?
(Please choose one.)

I feel healthy most of the time.
I feel okay most of the time.
I do not feel well most of the time.

2. What barriers do you have to participating in physical activity?
(Mark all that apply.)

	Barrier
	I don't feel safe.
	I don't feel comfortable exercising around others.
	I don't know where to start.
	I don't have time.
	It is not a priority.
	I do not feel good while exercising.
	My work schedule is erratic and/or demanding.
	I travel so much it is hard to get regular exercise.
	I just do not like to exercise.
	Health problems prevent me from doing activity.
	It's not convenient for me.
	I have no one to exercise with.
	There are no sidewalks or trails near my home.
	I have no family support.
	I have no peer support.
	I just lack motivation.
	I am satisfied with my current activity levels.
	I don't prioritize physical activity for my health.
	I don't have the appropriate clothing.
	I am afraid I will get hurt.
	My favorite activity is weather dependent.
	Family obligations do not allow me to take time for myself.
	I lack transportation to a physical activity facility (i.e. softball field).
	Other: Please type in:

3. Please indicate your agreement or disagreement with each statement:

a. I enjoy being physically active when I don't have to sweat. YES NO

b. I enjoy being physically active when I only sweat a little. YES NO

c. I enjoy being physically active when I break a good sweat YES NO

d. Obesity is a personal issue, not a community problem. YES NO

e. Gardening, yard work, and chopping wood are considered physical activity. YES NO

f. Physical activity can help reduce the risk of Type II diabetes. YES NO

g. Physical activity can help reduce mild depression. YES NO

h. Physical activity can reduce the risk of certain forms of cancer. YES NO

i. I get enough daily physical activity. YES NO

j. Physical activity turns fat into muscle. YES NO

k. I desire to be more physically active. YES NO

l. Obesity is an epidemic problem in the United States. YES NO

m. Urban Sprawl makes it harder to be physically active. YES NO

n. A connected trail and sidewalk system would make it easier for me to be active. YES NO

o. I enjoy walking to get places, such as the store. YES NO

p. I enjoy biking to get places, such as the store. YES NO

4. Where do you currently get physical activity information?
(Mark all that apply.)

		Medical care provider
		Family/friends
		Books
		Fitness club, community center or recreation dept.
		Exercise instructor/expert
		Newspaper
		On the internet
		TV
		Radio
		Magazine
		Other:

5. Where would you like to pick up health information?
(Mark your top two choices. Please choose 1 in column A and one in column B.)

A	B
		A. Worksite

		B. Church or religious center

		C. Convenience store

		D. Health care providers office

		E. Community center

		F. Stores, malls

		G. Library

		H. Grocery store

		I.Other

6. What type of physical activity information would you like to receive?
(Mark all that apply.)

		Sport specific
		General health
		Promotion of local activities/programs
		Basics of getting started
		Safe and effective weight loss techniques
		Active family options
		Other

Section 2: Work Status and Work Day
This section refers to time spent at WORK only.

7. On average, how many hours do you work per week?

8. Which one of the following best describes your work situation?
(Choose one.)

	I work outside the home
	I have a home-based business
	I'm a stay at home parent (go to section 3)
	I am retired (go to section 3)
	I am a student (go to section 3)
	I am unemployed (go to section 3)

9. Do you consider your job to be:
(Choose one.)

	Sedentary (often sit for more than 30 minutes at a time)
	Moderately active (often walk to get to other workers)
	Very active (always on the go, make deliveries, up and down steps all day)

10. Does your worksite provide any of these to encourage physical activity?
(Mark all that apply.)

	Workout room or designated area
	Sponsorship of employee sports teams
	Message campaigns encouraging physical activity
	Encouragement of stair usage
	Incentives for walking or biking to work
	Bike racks If yes, are they covered and secure? YES NO
	Walking trails
	Showers/locker rooms
	Physical activity classes
	Flex time for physical activities
	Subsidized club memberships
	Incentives for activities such as money or time off
	Encouragement from upper management to be physically active

Section 3: Leisure Time
This section refers to your leisure time only: (time that you use for activities of your choosing). It is NOT work time, or time set aside for regular workouts.

11. Do you rate your leisure time as:
(Choose one.)

	Sedentary (often sit for more than 30 minutes at any one time
	Moderately active (household chores, light recreational activity)
	Very active (always on the go, doing housework, yard work, playing with the kids)
	Other

12. Where do you spend most of your leisure time physical activity?
(Mark up to two responses-mark one in column A, and another in column B.)

A	B
		A. At home
		B. Community education facility
		C. Neighborhood streets
		D. Parks and recreation facility
		E. Neighborhood trails/sidewalks
		F. Mall
		GFitness center/club
		H. Local school building
		I. Other

13. What active leisure time activities do you participate in?
(Mark all that apply.)

	Team sports (any)
	Camp, hike
	Dog walking
	Lift/carry (i.e. kids)
	Canoe/kayak
	Vigorous house cleaning
	Sailing
	Home improvement project
	Rowing (boat)
	Gardening, yard work
	Water skiing
	Walk/bike for transportation
	Racquet sports
	Play with kids (tag, wrestle)
	Golf
	Rock climb
	Dance
	Ice skate
	Rake leaves
	In-line skate
	Shovel snow
	Bicycle touring/mountain
	Push stroller
	Shooting sports
	Swim
	Other

Section 4: Physical Activity Workouts
The following section refers to your time engaged in physical activity workouts only. (Time set aside to do a physical activity, not casual leisure time activities or work related activities).

14. On average, how many days per week do you engage in a physical activity workout?
(Choose one.)

	None (go to section 5)		Four
	One		Five
	Two		Six
	Three		Seven

15. On average, how many minutes per workout?

16. How many months per year are your workouts consistent?

17. Using the following list, indicate in the left column the one activity you do most often on your workout. In the right column indicate up to two other activities that you participate in.

Column A		Additional activities (up to two)
	Running
	Walking
	Bicycling
	Swimming
	Weight lifting
	Stair climbing
	Rowing machine
	Stationary bike
	Team sports
	Martial arts
	Aerobics
	Resistance/air ball/bands
	Workout video
	T'ai Chi
	Yoga
	Curves for Women
	X-country skiing, snowshoeing
	Racquet sports
	Other

18. Where do you most often workout?
(Mark up to two responses. Mark one in column A and the other in column B.)

A	B
		At home with video
		Fitness center/club
		At home with equipment
		Community education facility
		On neighborhood streets or trails
		Parks and/or recreation facilities
		Malls

Section 5: You and Your Community
Please answer all of the following questions. Are these statements true or false for you?

19.	I intend to increase my participation in moderate physical activity in the next 6 months.	True	False
20.	I currently participate in regular moderate physical activity	True	False
21.	In the past, I was regularly active in moderate activities for at least 3 months	True	False
22.	I have been getting regular physical activity for the past 6 months	True	False

Please answer all of the following questions with "Yes", "No", or "Unsure".

23. Does your community have:

A connected system of trails?	Yes	No	Unsure
A connected system of sidewalks?	Yes	No	Unsure
Bike lanes on roads?	Yes	No	Unsure
Parks and playgrounds?	Yes	No	Unsure
Organized walks?	Yes	No	Unsure
Organized physical activities?	Yes	No	Unsure
Public bike racks in convenient places?	Yes	No	Unsure
A public transit (bus) system? (if yes, please answer the next three questions)	Yes	No	Unsure
Have you ever ridden your public transit (bus)?	Yes	No	Unsure
Are you within walking distance to a bus route?	Yes	No	Unsure
Will bus routes take you where you want to go?	Yes	No	Unsure
Other community assets:

24. What will make it easier for you to be active?
(Mark all that apply.)

	Having a trail within 1/2 mile of my house
	Having a "hot line" to call for answers
	Having a resource center in the neighborhood
	Getting a monthly wellness newsletter
	Having recreation classes available locally
	Other

25. How far do you commute to work one way?

	I do not commute to work		Between 5.1and 8 miles
	Up to one mile		Between 8.1and 10 miles
	Between 1.1 and 5 miles		More than 10 miles

26. How far is it from home to your nearest regular destination? (i.e. grocery, video store, school, shops)?

	Don't know		Between 5.1and 8 miles
	Up to one mile		Between 8.1and 10 miles
	Between 1.1 and 5 miles		More than 10 miles

27. How often do you bike or walk for transportation to places you normally go?

Bike
	Never
	Once a week
	2-3 times/week
	4-7 times/week
	Over 7 times/week

Walk
	Never
	Once a week
	2-3 times/week
	4-7 times/week
	Over 7 times/week

28. If you do bike or walk for transportation, how far do you usually go one way?

Bike
	Up to one mile
	Between 1.1 and 5 miles
	Between 5.1 and 8 miles
	Between 8.1 and 10 miles
	More than 10 miles

Walk
	Up to one mile
	Between 1.1 and 5 miles
	Between 5.1 and 8 miles
	Between 8.1 and 10 miles
	More than 10 miles

29. In your opinion, how far is a reasonable distance to bike or walk for transportation?

Bike
	Up to one mile
	Between 1.1 and 5 miles
	Between 5.1 and 8 miles
	Between 8.1 and 10 miles
	More than 10 miles

Walk
	Up to one mile
	Between 1.1 and 5 miles
	Between 5.1 and 8 miles
	Between 8.1 and 10 miles
	More than 10 miles

30. What is the most effective encouragement to become healthier through activity?
(Mark up to two responses. Mark one in column A and one in column B).

A	B
		A. Joining family or friends in the activity
		B. Employer-paid fitness club membership
		C. Time off from work
		D. Friend/family member urging you on
		E. Activity facilities at work
		F. Having a coach/mentor
		G. Receiving regular reminders
		H. Insurance discount
		I. Trail system near home or work
		J. Feeling better over time
		K. Other A Other B

31. Who would be the strongest influence in your choice to be physically active?
(Mark one.)

	Significant other
	Co-worker
	Medical care provider
	Neighbor
	Other

	Son/daughter/parent
	Pastor/minister/rabbi
	Friend
	Famous person

a.	I enjoy being physically active when I don't have to sweat.	YES	NO
b.	I enjoy being physically active when I only sweat a little.	YES	NO
c.	I enjoy being physically active when I break a good sweat	YES	NO
d.	Obesity is a personal issue, not a community problem.	YES	NO
e.	Gardening, yard work, and chopping wood are considered physical activity.	YES	NO
f.	Physical activity can help reduce the risk of Type II diabetes.	YES	NO
g.	Physical activity can help reduce mild depression.	YES	NO
h.	Physical activity can reduce the risk of certain forms of cancer.	YES	NO
i.	I get enough daily physical activity.	YES	NO
j.	Physical activity turns fat into muscle.	YES	NO
k.	I desire to be more physically active.	YES	NO
l.	Obesity is an epidemic problem in the United States.	YES	NO
m.	Urban Sprawl makes it harder to be physically active.	YES	NO
n.	A connected trail and sidewalk system would make it easier for me to be active.	YES	NO
o.	I enjoy walking to get places, such as the store.	YES	NO
p.	I enjoy biking to get places, such as the store.	YES	NO