complementary and alternative medicine questionnaire · pdf file 2011-10-20 ·...

Complementary and Alternative Medicine Questionnaire

A CHIS 2001Follow-back study Contact:

Principal Investigator: E. Richard Brown, Ph.D. Director, UCLA Center for Health Policy Research Professor, UCLA School of Public Health UCLA Center for Health Policy Research 10911 Weyburn Avenue, Suite 300 Los Angeles, CA 90024, USA Telephone: 310-794-0812 Fax: 310-794-2686 Email: erbrown@ucla.edu

Project Director: Michael S. Goldstein, Ph.D.

Professor of Public Health, Department of Community Health Sciences School of Public Health University of California Los Angeles, CA 90095 Telephone: 310-825-5116 Email: msgoldst@ucla.edu

Copyright © 2002-2003 by the Regents of the University of California

Table of Contents Section AA (Introduction) ................................................................................................ 1 General Health .................................................................................................................... 1 Cancer diagnosis/diagnoses............................................................................................... 1 Type of cancer .................................................................................................................... 2 Chronic health conditions.................................................................................................... 4 Health insurance coverage ................................................................................................. 6

Section A (Use of Alternative Health Care Providers) ..................................................... 8 Section B (Use of Unconventional Cancer Therapies) .................................................. 14 Section C (Dietary Practices) ........................................................................................ 17 Section D (Use of Dietary Supplements) ...................................................................... 20 Section E (Use of Mind-Body Techniques).................................................................... 30 Section G (Spiritual Practices) ..................................................................................... 35

Section H (Participation in Physical Activity) ................................................................. 38

Section I (Use of Support Groups) ................................................................................ 40

CHIS-CAM Questionnaire September 5, 2003

Page 1

SECTION AA: INTRODUCTION AA1 As you may recall, our study is concerned with your health. In general, would you say your health is…

1. excellent, 2. very good, 3. good, 4. fair, or 5. poor?

AA2 Compared to the last time we interviewed you in ________[INSERT DATE FROM CHIS 2001], would you

say your health now is…

1. much better, 2. somewhat better, 3. about the same, 4. somewhat worse, or 5. much worse?

AA3 Has a doctor ever told you that you had a cancer of any kind?

1. YES GO TO AA4 2. NO GO TO Box AA-0 -7. REFUSED GO TO Box AA-0 -8. DON’T KNOW GO TO Box AA-0

Box AA-0 If R had cancer in CHIS 2001 interview, go to AA13, else go to Box AA-1A

CHIS-CAM Questionnaire September 5, 2003

Page 2

AA13 At the time we last interviewed you, we recorded that you had been diagnosed with cancer at some time in

the past. May I ask you why you didn’t mention that cancer when I asked you about your current health?

1. CANCER WAS CURED 2. CANCER IS IN REMISSION 3. FORGOT 4. THERE WAS A CHANGE IN MY DIAGNOSIS 5. DON’T LIKE TO TALK ABOUT IT 6. I NEVER HAD CANCER/INCORRECTLY RECORDED

Box AA-2A If change in diagnosis, don’t like to talk about it, never had cancer/incorrectly recorded, refused or don’t know change diagnosis to no cancer. Else if cancer cured, in remission, or respondent forgot, set R as having cancer. If R has cancer, go to AA4 Else, go to Box AA-1A AA4 How old were you when your cancer was first diagnosed? AGE: _________________ AA5 [1-4] What type of cancer was it?

CODE UP TO 4. RECORD EACH ON CONDITION LIST. 1 – 27 (CONDITION ON LIST) GO TO Box AA-1

91. OTHER (SPECIFY) GO TO Box AA-1 -7. REFUSED GO TO Box AA-1A -8. DON’T KNOW GO TO Box AA-1A

Box AA-1 If R had skin cancer, go to AA6 Else go to Box AA-1A

CHIS-CAM Questionnaire September 5, 2003

Page 3

AA6 Was your skin cancer a melanoma?

1. YES, MELANOMA 2. NO, NON-MELANOMA 3. BOTH MELANOMA AND NON-MELANOMA

Box AA-1A If R has any of the cancers listed in AA5 or skin cancer was melanoma or both melanoma and non-melanoma, go to AA7 Else if R does not have any of the cancers in AA5 or the only cancer is non-melanoma skin cancer, set R as no cancer and go to Box AA-1b Else if R has no cancer of any kind and AA13 is change in diagnosis, don’t like to talk about it, never had cancer/incorrectly recorded, don’t know, or refused, go to AA11_1 AA7 Are you seeing a doctor for your cancer now?

1. YES GO TO AA7OV 2. NO GO TO AA9 -7. REFUSED GO TO AA9 -8. DON’T KNOW GO TO AA9

AA7OV

Is the doctor a specialist?

1. YES GO TO AA8 2. NO GO TO AA9 -7. REFUSED GO TO AA9 -8. DON’T KNOW GO TO AA9

AA8 What type of specialist? (SEE SPECIALIST LIST)

[IF MORE THAN ONE: What type of specialist do you see most often for your cancer?]

1 – 27 (TYPE OF SPECIALIST) 91. OTHER (SPECIFY) _______________________________

CHIS-CAM Questionnaire September 5, 2003

Page 4

AA9 Over the past 30 days, how much has the cancer or cancer treatment kept you from working or doing things

that you want to do? Would you say…

1. a great deal, 2. somewhat, 3. a little, or 4. not at all?

AA10 Over the past 30 days, how much pain or discomfort has the cancer or the cancer treatment caused you?

Would you say…

1. a great deal, 2. some, 3. a little, or 4. none at all?

AA11_1

Now I have some more questions about your health. Do you now have… [FOR ALL ITEMS EXCEPT B AND F – IF THE RESPONDENT IS UNSURE, PROBE: Has a doctor or other health professional told you that you have…]

AA11AST

a. asthma?

1. YES 2. NO

AA11LUN

b. any other lung or breathing problem?

1. YES 2. NO

AA11HRT

c. a heart condition or cardiovascular disease?

1. YES 2. NO

AA11CRN

d. chronic obstructive pulmonary disease or COPD?

1. YES 2. NO

CHIS-CAM Questionnaire September 5, 2003

Page 5

AA11ART e. arthritis or rheumatism?

1. YES 2. NO

AA11BAC

f. back or neck problems?

1. YES 2. NO

AA11_2

Have you ever had a stroke?

1. YES 2. NO

AA11_3

Do you now have… AA11DIA

h. diabetes?

1. YES 2. NO

AA11BLO

i. high blood pressure or hypertension?

1. YES 2. NO

AA11DEP

j. depression or anxiety disorder?

1. YES 2. NO

AA11OTH

k. any other conditions I have not mentioned?

1. YES GO TO AA11_4 2. NO GO TO AA12 -7. REFUSED GO TO AA12 -8. DON’T KNOW GO TO AA12

CHIS-CAM Questionnaire September 5, 2003

Page 6

AA11_4 [A-J] What other conditions do you have? [LIST UP TO 10]

CONDITION A – J:

AA12 {Besides the cancer you told me about earlier, over/Over} the past 30 days, how much has your health kept

you from working or doing things that you want to do? Would you say…

1. a great deal, 2. somewhat, 3. a little, or 4. not at all?

AA14 Do you currently have health insurance or an HMO that pays any of the cost of medical care?

[IF NECESSARY: Include health insurance or an HMO you might get through an employer or union, and include Medicare, Medi-Cal, Healthy Families, Tricare or any other military health plan, or any other health coverage through a government program.]

1. YES GO TO AA14A 2. NO GO TO AA14B -7. REFUSED GO TO AA14B -8. DON’T KNOW GO TO AA14B

AA14A Is that the same insurance or HMO coverage that you had when we interviewed you in {MONTH/YEAR

CHIS INTERVIEW}?

1. YES GO TO SECTION A 2. NO GO TO AA15 -7. REFUSED GO TO AA15 -8. DON’T KNOW GO TO AA15

AA14B Have you been covered at any time in the past 12 months by health insurance or an HMO that pays any of

the cost of medical care?

1. YES GO TO AA15 2. NO GO TO SECTION A -7. REFUSED GO TO SECTION A -8. DON’T KNOW GO TO SECTION A

CHIS-CAM Questionnaire September 5, 2003

Page 7

AA15 {Was/Is} your health insurance or HMO through {an/a current or former} employer (either your own or

someone else’s)?

1. YES GO TO SECTION A 2. NO GO TO AA15A -7. REFUSED GO TO AA15A -8. DON’T KNOW GO TO AA15A

AA15A {Was/Is} it purchased directly from an insurance company or HMO?

1. YES GO TO SECTION A 2. NO GO TO Box AA-3A -7. REFUSED GO TO Box AA-3A -8. DON’T KNOW GO TO Box AA-3A

Box AA-3A If Age > 65, go to