HSC 3211_Pilot Survey Tool Worksheet_Guilefuss
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St. Petersburg College *
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Health Science
Date
Feb 20, 2024
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doc
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HSC 3211: Pilot Survey Tool Worksheet
Student Name: Leah Sindt
The Focus of Your Research
Fill out each box.
1.
Health Behavior.
Select a specific health behavior you will be focusing on (e.g. brushing
teeth 2x/day or signing up for benefits such as SNAP):
Getting the Flu shot
2.
Target Audience.
Select a specific segment of a population to be your target audience (e.g. students who qualify for Medicaid or residents of Magnolia Heights):
Over age of 65 3.
Behavioral Model
. Check any behavioral models you will be using to formulate your questions (all of these are explained in detail in the Module 3 Interactive Lesson):
□ Social Cognitive Theory (SCT)
□ Theory of Reasoned Action (TRA)
□ Transtheoretical Model (TTM)
□ Theory of Planned Behavior (TPB)
□ Health Belief Model (HBM)
□ Integrative Behavioral Model (IBM)
Your Original Survey Questions
If you need help designing good survey questions, follow the link at the bottom of “Module 3 Assignment: Pilot Survey” instructions to watch the “Designing Surveys” video. Remember, survey questions should be:
Brief
Use close-ended questions/statements
More personal towards the end (i.e tough questions, demographics, etc.)
Free and clear of leading questions
Questions interpreted the same by anyone who reads them
Use answers that are mutually exclusive (do not overlap) and complete (all options accounted for)
Seven of the questions below should be original survey questions you create from the behavioral models we learned about. Three questions are reserved at the end for demographic questions (e.g. gender, age, whether or not they fall within your target audience, etc.). Remember to be inclusive with your answer options. It is good ethical practice to include an “I prefer not to
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disclose” option on demographic questions. The “Participant Responses” area will be filled out when you actually conduct your survey with 10 people.
Example 1 Question:
How likely are you to get a cavity?
Example 1 Answers:
a. Very likely
b. Likely
c. Not sure
d. Unlikely
e. Very unlikely
Participant Responses:
1
2
3
4
5
6
7
8
9
10
d
b
d
d
b
a
e
d
e
d
Behavioral Model Used:
□ SCT □ TTM X
HBM □ TRA □ TPB □ IBM Construct being measured from Behavioral Model: Perceived susceptibility
Example 2 Question:
“I have recently bought nicotine patches, nicotine gum, e-
cigarettes, vape pen, or other products to help me quit smoking.”
Example 2 Answers:
a.
Yes
b.
No
Participant Responses:
1
2
3
4
5
6
7
8
9
10
b
b
b
a
b
b
b
b
b
b
Behavioral Model Used:
□ SCT X
TTM □ HBM □ TRA □ TPB □ IBM Construct being measured from Behavioral Model: Preparation
Question 1: How likely are you to get the flu shot?
Answers 1:
a.
Very likely b.
Likely c.
Not Sure d.
Unlikely Participant Responses:
1
2
3
4
5
6
7
8
9
10
A
A
A
B
B
D
A
A
B
A
Behavioral Model Used:
□ SCT □ TTM □ HBM □ TRA □ TPB □ IBM Construct being measured from Behavioral Model: Perceived Susceptibility Question 2: I have recently made an appointment to get the flu
shot?
Answers 2:
a.
Yes
Behavioral Model Used:
□ SCT □ TTM □ HBM □ TRA □ TPB □ IBM Construct being measured from Behavioral Model:
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b.
No
Participant Responses:
1
2
3
4
5
6
7
8
9
10
A
A
A
A
A
A
B
B
A
B
Self-Efficacy Question 3: Have you ever gotten a flu shot before?
Answers 3:
A. Yes
B. No
Participant Responses:
1
2
3
4
5
6
7
8
9
10
A
A
A
A
A
A
A
B
B
A
Behavioral Model Used:
□ SCT □ TTM □ HBM □ TRA □ TPB □ IBM Construct being measured from Behavioral Model: Cues to Action Question 4: How likely are you to recommend a flu shot to
others?
Answers 4:
A.
Very likely
B. Likely
C.
Not likely
D. Unsure
E.
Very unlikely Participant Responses:
1
2
3
4
5
6
7
8
9
10
A
A
A
B
A
B
D
D
D
A
Behavioral Model Used:
□ SCT □ TTM □ HBM □ TRA □ TPB □ IBM Construct being measured from Behavioral Model: Precontemplation Question 5: Do you feel you will get sick after getting the flu
shot?
Answers 5:
A. Yes B. No
C. Unsure Participant Responses:
1
2
3
4
5
6
7
8
9
10
B
B
A
A
A
B
C
C
C
A
Behavioral Model Used:
□ SCT □ TTM □ HBM □ TRA □ TPB □ IBM Construct being measured from Behavioral Model: Perceived Barriers Question 6: Where do you go for the flu shot?
Behavioral Model Used:
□ SCT □ TTM □ HBM □ TRA □ TPB □ IBM
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Answers 6:
A. CVS
B. Walgreens
C.
Local pharmacy
D. Unsure Participant Responses:
1
2
3
4
5
6
7
8
9
10
A
A
A
A
A
A
D
D
D
B
Construct being measured from Behavioral Model: Maintenance Question 7: What factors deter you from getting your flu shot?
Answers 7:
A. Sickness
B.
Sore Arm
C. Swelling
D.
None of the above E.
All the above Participant Responses:
1
2
3
4
5
6
7
8
9
10
D
D
D
D
D
D
E
A
E
B
Behavioral Model Used:
□ SCT □ TTM □ HBM □ TRA □ TPB □ IBM Construct being measured from Behavioral Model: Perceived Severity Question 8: What benefits do you love about the flu shot?
Answers 8:
A.
Reduced Hospitalization B.
Reduced Risk of the Flu
C.
Boosting your immune system D.
All of the above Participant Responses:
1
2
3
4
5
6
7
8
9
10
D
D
D
D
D
D
D
D
D
D
Use this one as a demographic
question.
Question 9: Who do you feel is at a higher risk for the flu without
the flu shot?
Answers 9:
A.
Under the age of 5
B. 5-10
C. 10-20
D. 20-30
E. 30-40
F.
40-50
G.
Over the age of 65 Participant Responses:
Use this one as a demographic
question.
5
1
2
3
4
5
6
7
8
9
10
A
A
A
G
G
G
A
A
A
G
Question 10: Do you feel the flu shot should be given passed a
certain age?
Answers 10:
A. Yes
B. No
C. Unsure Participant Responses:
1
2
3
4
5
6
7
8
9
10
A
A
C
C
C
B
B
B
C
A
Use this one as a demographic
question.
Conducting your Survey
Conduct your survey with about 10 people and collect the results using the “Participant Responses” section in the above table (you can do more than 10 if you have the time!). If you have access to your target audience, great! If you do not, then “pretest” your survey with other people you do have access to. Feel free to digitize your survey by plugging your questions into surveymonkey.com or using social media such as Facebook to share your questions. You can also conduct a paper survey or call people by phone. Sometimes recruiting people is the hardest part (Tip: many people are sympathetic to students if you explain you are conducting a pilot survey on a health issue for school).
Informed Consent:
Explain to each person what the survey is for, tell them that it is anonymous, and ask each person for verbal consent to participate by asking them something like,
“would you like to participate?”. DO NOT collect personally identifiable information such as their name, contact info, address, etc. In a real IRB approved research study, you would be required to collect written informed consent from each person, but that is not necessary in this case since this is formative research for a school project.
Reporting your Results
Show your aggregate results for each question below (meaning the sum of all participants’ responses). There are several ways to do this. Two examples are shown below. Be sure that each table/graph is labeled with the question in the title. Each part should be properly labeled with the answer and total frequency of people who selected that answer. It is good to include the frequency of people and/or the percentage. After you visually depict the results, give a summary of about 100-200 words at the end on what you learned from this experience and the results.
Example 1: Frequency Table
How likely are you to get a cavity?
Answer
Frequency
Percentage
6
Very likely
1
10%
Likely
2
20%
Not sure
0
0%
Unlikely
5
50%
Very unlikely
2
20%
In the final summary, since this question is measuring “perceived susceptibility” in HBM, I would say that it seems like my audience’s perceived susceptibility is low
since 70 percent feel they are “unlikely” or “very unlikely” to get a cavity.
Example 2: Pie Chart
In the summary, since this question is measuring “preparation” within TTM, I would say that only one person fell within the preparation phase of the Stages of Change. If I had a demographic question later on asking if they ever smoked, and most of them said “No”, then I could explain that the reason 90% of people were not in the preparation phase is because most of my participants did not fall within the target audience of people who have smoked.
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Question 1 Results. Question 2 Results.
8
Question 3 Results.
Question 4 Results.
9
Question 5 Results. Question 6 Results.
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Question 7 Results.
Question 8 Results.
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Question 9 Results.
Question 10 Results.
Summary of Experience and Findings:
This experience was very interesting and getting with a group of elders over 65 and learning their experience and learning their point of view was very neat to learn. It was neat to learn about how they feel about the younger generation as well, and how they want them to take care of their health. The health behavior model and transtheoretical model was the best option to reflect this survey because it shows how the elder look at their actions and it shows the outlooks they have on their behaviors as well.
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