OMB#: 0920-0673 Expiration Date: 02/28/2007 RESPONDENT ID................. DATE................ INTERVIEWER.. TOTAL TIME..................................... ARTHRITIS CONDITIONS HEALTH EFFECTS SURVEY (ACHES) SPECIFICATIONS Prepared for: Centers for Disease Control and Prevention Arthritis Program Prepared by: Battelle Centers for Public Health Research and Evaluation Baltimore, Maryland April 2005 Arthritis Conditions Health Effects Survey (ACHES) Page 1 START TIME................................................... : SECTION 1: GENERAL FUNCTION I would like to start with some general background questions. GF1. In general, would you say that your health is (READ Excellent..................................................................................1 ANSWERS)? Very good................................................................................2 Good........................................................................................3 Fair...........................................................................................4 Poor.........................................................................................5 DK.............................................................................................8 RF.............................................................................................9 The question only refers to the Respondent’s health in GENERAL. Be sure to read all answer choices before accepting an answer. GF2. Are you now limited in any way in any of your usual NO.............................................................................................0 activities because of arthritis or joint symptoms? YES...........................................................................................1 DK.............................................................................................8 RF.............................................................................................9 This question is only about the limitation R has now and only because of arthritis or joint symptoms. In this and the following question, if R asks what we mean by “usual” you should respond with “Whatever you think usual is”. GF3. How satisfied are you with your current ability to do Very satisfied..........................................................................1 your usual activities? Are you (READ ANSWERS)? Somewhat satisfied...............................................................2 Neither satisfied nor dissatisfied.........................................3 Somewhat dissatisfied..........................................................4 Very dissatisfied.....................................................................5 DK.............................................................................................8 RF.............................................................................................9 We want to know how R feels about his/her ability to do usual activities. Again, be sure to read all answer choices before accepting an answer. SECTION 2: SYMPTOMS Next we want to ask about your symptoms. SX1. Over the past 7 days, how many days have you had NUMBER OF DAYS....................................................... pain or aching from arthritis or joint symptoms? DK...........................................................................................98 RF...........................................................................................99 While the first set of questions had no defined timeframe, the questions in this section only refer to the past 7 days. The first answer should be a number between 0 and 7. Arthritis Conditions Health Effects Survey (ACHES) Page 2 The next three questions use a 0 to 10 point scale. ROUND OFF VALUES; 0.5 ROUND UP. SX2. On a scale of 0 to 10 where 0 is no pain or aching and RATE 0 -10.................................................................... 10 is pain or aching as bad as it could be, over the DK...........................................................................................98 past 7 days, on average how bad was your joint pain RF...........................................................................................99 or aching? SX2, SX3, and SX4 all use a 0 to 10 point scale, with different anchor terminology. Please be sure R is focused on this. If you get an answer that is not a number, read the scale details again. If you get an answer that is not a whole number, round to the closest whole number. Values of .5 get rounded up. So 3.3 is a 3, but 3.5 is a 4. SX3. On a scale of 0 to 10, where 0 is no joint stiffness and RATE 0 -10.................................................................... 10 is joint stiffness as bad as it could be, over the past DK...........................................................................................98 7 days, on average how much joint stiffness have you RF...........................................................................................99 had? SX4. On a scale of 0 to 10, where 0 is no fatigue and 10 is RATE 0 -10.................................................................... fatigue as bad as it could be, over the past 7 days, on DK...........................................................................................98 average how much fatigue have you had because of RF...........................................................................................99 your arthritis or joint symptoms? SX5. Have you taken any prescription or non-prescription NO.............................................................................................0 medication for these joint symptoms in the past 7 YES...........................................................................................1 DK.............................................................................................8 days? RF.............................................................................................9 This question refers to both prescription and non-prescription medications taken for arthritis or joint symptoms. SECTION 3: PHYSICAL FUNCTIONING SCALE (SF36 V2) Now I am going to read a list of activities you might do during a typical day. As I read each item please tell me if your health now limits you a lot, limits you a little, or does not limit you at all in these activities. SF1. First vigorous activities such as running, lifting heavy A LOT........................................................................................1 objects, participating in strenuous sports? Does your A LITTLE...................................................................................2 NOT AT ALL.............................................................................3 health now limit you a lot, limit you a little, or not limit DK.............................................................................................8 you at all? RF.............................................................................................9 The questions in this section are part of a physical functioning scale. These are standard questions and must be read exactly as they are written. They refer to R’s health in general, not just arthritis or joint symptoms. You should be very careful to read these items slowly as many have very similar wording and could become confusing when read. If R says that you already asked that question, repeat the question emphasizing the part that differs from the previous question. SF2. Moderate activities such as moving a table, pushing a A LOT........................................................................................1 vacuum cleaner, bowling, or playing golf? Does your A LITTLE...................................................................................2 NOT AT ALL.............................................................................3 health now limit you a lot, limit you a little, or not limit DK.............................................................................................8 you at all? RF.............................................................................................9 Arthritis Conditions Health Effects Survey (ACHES) Page 3 SF3. Lifting or carrying groceries? (Does your health now A LOT........................................................................................1 limit you a lot, limit you a little, or not limit you at all?) A LITTLE...................................................................................2 NOT AT ALL.............................................................................3 DK.............................................................................................8 RF.............................................................................................9 After the first two times of reading all of the answer choices before accepting an answer, if R understands the scale you do not have to repeat the answers for the later questions. However, you should read the answers anytime R needs them. SF4. Climbing several flights of stairs? (Does your health A LOT........................................................................................1 now limit you a lot, limit you a little, or not limit you at A LITTLE...................................................................................2 NOT AT ALL.............................................................................3 all?) DK.............................................................................................8 RF.............................................................................................9 SF5. Climbing one flight of stairs? (Does your health now A LOT........................................................................................1 limit you a lot, limit you a little, or not limit you at all?) A LITTLE...................................................................................2 NOT AT ALL.............................................................................3 DK.............................................................................................8 RF.............................................................................................9 SF6. Bending, kneeling, or stooping? (Does your health A LOT........................................................................................1 now limit you a lot, limit you a little, or not limit you at A LITTLE...................................................................................2 NOT AT ALL.............................................................................3 all?) DK.............................................................................................8 RF.............................................................................................9 SF7. Walking more than a mile? (Does your health now A LOT........................................................................................1 limit you a lot, limit you a little, or not limit you at all?) A LITTLE...................................................................................2 NOT AT ALL.............................................................................3 DK.............................................................................................8 RF.............................................................................................9 SF8. Walking several hundred yards? (Does your health A LOT........................................................................................1 now limit you a lot, limit you a little, or not limit you at A LITTLE...................................................................................2 NOT AT ALL.............................................................................3 all?) DK.............................................................................................8 RF.............................................................................................9 If R asks how far is several hundred yards, you should say “the length of approximately 3 to 4 football fields”. SF9. Walking one hundred yards? (Does your health now A LOT........................................................................................1 limit you a lot, limit you a little, or not limit you at all?) A LITTLE...................................................................................2 NOT AT ALL.............................................................................3 DK.............................................................................................8 RF.............................................................................................9 100 yards is the length of one football field. SF10. Bathing or dressing yourself? (Does your health now A LOT........................................................................................1 limit you a lot, limit you a little, or not limit you at all?) A LITTLE...................................................................................2 NOT AT ALL.............................................................................3 DK.............................................................................................8 RF.............................................................................................9 Arthritis Conditions Health Effects Survey (ACHES) Page 4 SECTION 4: WORK EFFECTS WK1. Are you currently (READ ANSWERS)? IF RESPONDENT Employed for pay................(SKIP TO WK2).........................1 OFFERS MORE THAN ONE CATEGORY, ASK: What best Self-employed.....................(SKIP TO WK2).........................2 describes your situation? CODE ONLY ONE. Out of work.............................................................................3 A homemaker.....................(SKIP TO WK2).........................5 Student................................(SKIP TO WK2).........................6 Or retired.............................(SKIP TO WK2).........................7 DK.........................................(SKIP TO WK2).......................98 RF.........................................(SKIP TO WK2).......................99 Read the first part of the question along with all of the answers. This question is NOT a code all that applies. If R gives you more then one answer, use the probe provided to get a single answer that best represents R’s current situation. With the exception of “Out of Work” you will skip to WK2. (WK1A.) Have you been out of work for more than 1 year or MORE.......................................................................................1 less than 1 year? LESS.........................................................................................2 DK.............................................................................................8 RF.............................................................................................9 The only time this question is read is when R has told you they are out of work. PROGRAMMER NOTE: IF LESS THAN 1 YEAR, CODE WK1 = 4. WK2. Do arthritis or joint symptoms now affect whether you NO.............................................................................................0 work for pay or not? YES...........................................................................................1 DK.............................................................................................8 RF.............................................................................................9 Everyone will be asked this question. It refers to how arthritis or joint symptoms affect whether R works for pay or not. If R answers that he/she does not work for pay, repeat the question emphasizing the first part. IF WK1 = 1 OR 2 (EMPLOYED OR SELF EMPLOYED), ASK WK3 THRU WK5. OTHERWISE, SKIP TO WK6. WK3. Do arthritis or joint symptoms affect the type of work NO.............................................................................................0 you do? YES...........................................................................................1 N/A (SKIP)................................................................................7 DK.............................................................................................8 RF.............................................................................................9 WK3, WK4 and WK5 are only asked of Rs who are employed for pay or self-employed. They again focus on how arthritis or joint symptoms affect aspects of R’s employment. WK4. Do arthritis or joint symptoms affect the amount of NO.............................................................................................0 work you do? YES...........................................................................................1 N/A (SKIP)................................................................................7 DK.............................................................................................8 RF.............................................................................................9 Arthritis Conditions Health Effects Survey (ACHES) Page 5 WK5. In the past 30 days, how many days of work did you NUMBER OF DAYS....................................................... miss because of arthritis or joint symptoms? N/A (SKIP)..............................................................................97 DK...........................................................................................98 RF...........................................................................................99 This question refers to the past 30 days only. The answer should be a number between 0 and 30. IF WK1 = 1 OR 98 OR 99 (EMPLOYED, DK, OR RF), SKIP TO WK7. WK6. Is your arthritis or joint symptoms the main reason NO.............................................................................................0 you are (EMPLOYMENT STATUS)? YES...........................................................................................1 N/A (SKIP)................................................................................7 DK.............................................................................................8 RF.............................................................................................9 This question will only be asked of Rs who reported an employment status other than employed for pay. The CATI will display the correct words to read based on the answer to WK1. PROGRAMMER NOTE: IF WK2 = 2, EMPLOYMENT STATUS = SELF-EMPLOYED. IF WK2 = 3 OR 4, STATUS = OUT OF WORK. IF WK1 = 5, STATUS = A HOMEMAKER AND NOT WORKING FOR PAY. IF WK1 = 6, STATUS = A STUDENT AND NOT WORKING FOR PAY. IF WK1 = 7, STATUS = RETIRED. These next questions refer to volunteer work, that is work outside your home for which you are not paid. WK7. Do you currently do volunteer work? NO.............................................................................................0 YES................................(SKIP TO WK9).................................1 DK........................(SKIP TO NEXT SECTION)........................8 RF........................(SKIP TO NEXT SECTION)........................9 All Rs will be asked about volunteer work, defined in the intro statement as work outside of the home for which R is not paid. The answer will determine which follow-up question is asked to determine the affect arthritis and joint symptoms have on volunteer work. WK8. Is arthritis or joint symptoms the main reason you do NO.............................................................................................0 not do volunteer work? YES...........................................................................................1 N/A (SKIP)................................................................................7 DK.............................................................................................8 RF.............................................................................................9 SKIP TO NEXT SECTION. WK9. Do arthritis or joint symptoms affect the amount or NO.............................................................................................0 type of volunteer work you do? YES...........................................................................................1 N/A (SKIP)................................................................................7 DK.............................................................................................8 RF.............................................................................................9 Arthritis Conditions Health Effects Survey (ACHES) Page 6 SECTION 5: INTERFERENCE The next questions refer to how arthritis or joint symptoms may affect your life. During the past 7 days, how much did your arthritis or joint symptoms interfere with the following activities? INT1. Getting a good night’s sleep? Did arthritis or joint A LOT........................................................................................1 symptoms interfere a lot, a little, or not at all in the A LITTLE...................................................................................2 NOT AT ALL.............................................................................3 past 7 days? DK.............................................................................................8 RF.............................................................................................9 The questions in this section focus on how arthritis and joint symptoms may interfere with R’s daily activities. The first four questions ask about the past 7 days. When you read these, please be certain R is focused on the past 7 days. You can leave off reading the answer choices once R becomes familiar with the scale. INT2. Recreation, leisure, or hobbies? Did arthritis or joint A LOT........................................................................................1 symptoms interfere a lot, a little, or not at all in the A LITTLE...................................................................................2 NOT AT ALL.............................................................................3 past 7 days? DK.............................................................................................8 RF.............................................................................................9 INT3. Household chores? (Did arthritis or joint symptoms A LOT........................................................................................1 interfere a lot, a little, or not at all in the past 7 days?) A LITTLE...................................................................................2 NOT AT ALL.............................................................................3 DK.............................................................................................8 RF.............................................................................................9 INT4. Errands or shopping? (Did arthritis or joint symptoms A LOT........................................................................................1 interfere a lot, a little, or not at all in the past 7 days?) A LITTLE...................................................................................2 NOT AT ALL.............................................................................3 DK.............................................................................................8 RF.............................................................................................9 INT5. During the past 30 days, to what extent did your A LOT........................................................................................1 arthritis or joint symptoms interfere with your normal A LITTLE...................................................................................2 NOT AT ALL.............................................................................3 social activities with family, friends, neighbors, or DK.............................................................................................8 groups? A lot, a little, or not at all? RF.............................................................................................9 The final question shifts to asking about the past 30 days. Be sure that you emphasize this new timeframe. Arthritis Conditions Health Effects Survey (ACHES) Page 7 SECTION 6: ATTITUDES Next I will read 5 statements and ask you to tell me if you strongly agree, agree, are neutral, disagree, or strongly disagree with each. ATT1. There is nothing a person with arthritis or joint Strongly agree........................................................................1 symptoms can do to make their arthritis better. Do you Agree.......................................................................................2 (READ ANSWERS)? Are Neutral..............................................................................3 Disagree..................................................................................4 Strongly disagree...................................................................5 DK.............................................................................................8 RF.............................................................................................9 The next questions ask about R’s attitude to certain statements. There are no right or wrong answers. The answer choices are very similar in sound so you should read them slowly until R fully understands and hears the options of agree and disagree. ATT2. It is important for someone with arthritis or joint Strongly agree........................................................................1 symptoms to see a doctor for diagnosis and Agree.......................................................................................2 treatment. Do you (READ ANSWERS)? Are Neutral..............................................................................3 Disagree..................................................................................4 Strongly disagree...................................................................5 DK.............................................................................................8 RF.............................................................................................9 ATT3. It is important for someone with arthritis or joint Strongly agree........................................................................1 symptoms to get moderate physical activity three or Agree.......................................................................................2 more days of the week. (Do you [READ ANSWERS])? Are Neutral..............................................................................3 Disagree..................................................................................4 Strongly disagree...................................................................5 DK.............................................................................................8 RF.............................................................................................9 ATT4. It is important for someone with arthritis or joint Strongly agree........................................................................1 symptoms to stay at a normal body weight or lose Agree.......................................................................................2 excess weight. (Do you [READ ANSWERS])? Are Neutral..............................................................................3 Disagree..................................................................................4 Strongly disagree...................................................................5 DK.............................................................................................8 RF.............................................................................................9 ATT5. It is important for someone with arthritis or joint Strongly agree........................................................................1 symptoms to participate in a course or class to learn Agree.......................................................................................2 how to manage their condition. (Do you [READ Are Neutral..............................................................................3 ANSWERS])? Disagree..................................................................................4 Strongly disagree...................................................................5 DK.............................................................................................8 RF.............................................................................................9 Arthritis Conditions Health Effects Survey (ACHES) Page 8 SECTION 7: CONFIDENCE The next 4 questions are about confidence. They are answered using a 10 point scale where 0 is not at all confident and 10 is as confident as you can be. CON1. How confident are you that you can manage your RATE 0 -10.................................................................... arthritis or joint symptoms? (Using a 10 point scale DK...........................................................................................98 where 0 is not at all confident and 10 is as confident RF...........................................................................................99 as you can be.) The four questions in this section all use a 0 to 10 point scale with the same anchor terminology. You do not need to read the scale details with each question if R responds with a whole number between 0 and 10. Use the same rounding rules as before. CON2. How confident are you that taking a course or class RATE 0 -10.................................................................... would help you manage your arthritis or joint DK...........................................................................................98 symptoms? (Using a 10 point scale where 0 is not at RF...........................................................................................99 all confident and 10 is as confident as you can be.) Assuming that you want to, how confident are you that you can do each of the following things for at least 3 months starting within the next 7 days. CON3. How confident are you that you can get moderate RATE 0 -10.................................................................... physical activity three or more days of the week? DK...........................................................................................98 (Using a 10 point scale where 0 is not at all confident RF...........................................................................................99 and 10 is as confident as you can be.) The last two questions ask about R’s confidence is sustaining activities that would start within the next 7 days (or continue if R already does them). CON4. How confident are you that you can stay at a normal RATE 0 -10.................................................................... body weight or lose excess weight? (Using a 10 point DK...........................................................................................98 scale where 0 is not at all confident and 10 is as RF...........................................................................................99 confident as you can be.) SECTION 8: SELF MANAGEMENT SM1. Have you ever contacted the Arthritis Foundation? NO.............................................................................................0 YES...........................................................................................1 DK.............................................................................................8 RF.............................................................................................9 SM2. Have you ever taken a course or class to teach you NO.............................................................................................0 how to manage problems related to your arthritis or YES...........................................................................................1 DK.............................................................................................8 joint symptoms? RF.............................................................................................9 SM3. Are you trying to lose weight? NO.............................................................................................0 YES...........................................................................................1 DK.............................................................................................8 RF.............................................................................................9 Arthritis Conditions Health Effects Survey (ACHES) Page 9 SM4. Do you take glucosamine for your arthritis or joint NO.............................................................................................0 symptoms? YES...........................................................................................1 DK.............................................................................................8 RF.............................................................................................9 If R is taking this drug, he/she will immediately tell you yes. This medication can be purchased over the counter and can be beneficial in the easement of arthritis pain. It is pronounced as glue-coe-sa-meen. If R asks you if this is something he/she should be using, tell R to discuss it with his/her regular health care provider. Note that chondroitin (kon-drow- tin) is not the same as glucosamine. SECTION 9: STAGE OF CHANGE FOR PHYSICAL ACTIVITY Physical activity or exercise includes activities such as walking briskly, jogging, bicycling, swimming, or any other activity in which exertion is at least as intense as these activities. SOC1. Are you currently physically active? NO.............................................................................................0 YES...........................................................................................1 DK.............................................................................................8 RF.............................................................................................9 This is the first of two sections that focus on physical activity. While the intro statements that you will read provide examples of activities with varying levels of intensity, these are only examples. Any activity that R considers similar is fine to include. SOC2. Do you intend to become more physically active in the NO.............................................................................................0 next 6 months? YES...........................................................................................1 DK.............................................................................................8 RF.............................................................................................9 For activity to be regular, it must add up to a total of 30 minutes or more per day and be done at least 3 days per week. For example, you could take one 30-minute walk or take three 10-minute walks for a daily total of 30 minutes. SOC3. Do you currently engage in regular physical activity? NO.............................................................................................0 YES...........................................................................................1 DK.............................................................................................8 RF.............................................................................................9 SOC3 and SOC4 refer to regular activity. The intro defines what is meant by regular and you can repeat this definition if needed. Note that regular has two parts – 30 minutes or more per day AND at least 3 days a week. SOC4. Have you been regularly physically active for the last NO.............................................................................................0 6 months? YES...........................................................................................1 DK.............................................................................................8 RF.............................................................................................9