HEP 456 Module 4 Health Belief Model Questionnaire

HEP 456: Health Promotion Program Eval

Arizona State University

Dean Helitzer

11th November 2022

‘Living Well on Dialysis’ Intervention Program Survey

This intervention program targets dialysis patients between the age of 25-40. The aim of this survey is to help the program evaluators learn how the participants feel about their perceived susceptibility, barriers, severity, benefits, self-efficacy, and cues action.

Each question has 5 levels of answers marked as 1,2,3,4, and 5.

Their representations are listed below:

1- Strongly Agree

2- Agree

3- Neutral

4- Disagree

5- Strongly Disagree

‘LIVING WELL ON DIALYSIS’ PROGRAM QUESTIONNAIRE

PERCEIVED SEVERITY

1 2 3 4 5

1. I am cognizant of the risks associated with hypertension in dialysis patients.

2. I am aware that unmanaged high and low blood pressures are fatal to dialysis patients.

3. I am aware that among those dialysis patients struggling with hypertension, only 30-50% have it in control.

PERCEIVED SUSCEPTIBILTY

1 2 3 4 5

4. I am aware that most of dialysis patients in my age group are not keen on hypertension management.

5. I am aware that 70-80 % of dialysis patients are also struggling with hypertension.

PERCEIVED BENEFITS

1 2 3 4 5

6. I will be able to live well on dialysis.

7. My diet will improve.

8. I will have self-awareness on hypertension.

9. I will learn the hypertension’s coping techniques.

10. I will live longer and healthier.

CUES TO ACTION

1 2 3 4 5

11. I would like to know more about this intervention program.

12. I am interested in meeting other patients and staff and will work together for a better tomorrow.

13. I am ready to follow the laid program schedule.

PERCEIVED BARRIERS

1 2 3 4 5

14. The change in diet will be uncomfortable.

15. The program is time-consuming.

16. The location of the program i.e., Gulf Memorial Hospital is a bit far from my residence.

SELF EFFICACY

1 2 3 4 5

17. I can make commitment and attend the dialysis program as planned.

18. I do not mind getting calls after completion for outcome evaluation.

19. I can take time off from work to participate in the program

DEMOGRAPHIC QUESTIONS

20. What is your birth date? Write in, month, day, year _ _ / _ _/ _ _ _ _

21. What is your highest level of education? Middle school High school or GED Associate’s degree College Graduate school

22. What is your race? BLACK HISPANIC AMERICAN

INDIAN ASIAN WHITE

23. What is your ethnicity? Hispanic Non-Hispanic

24. What is your gender? Male Female Transgender None of these

This section is for you to give your thoughts on the aforementioned questions and anything else you feel like highlighting.