WP1b and 2. Father and Children’s Baseline Questionnaires

Father’s baseline questionnaire V2.0: 22-11-2016

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FATHER’S QUESTIONNAIRE

Baseline

Please answer every question as honestly as you can. If you are unsure about how to answer a question, mark the response for the

closest answer to how you feel.

Father ID

Father initials

Researcher name

Father’s baseline questionnaire V2.0: 22-11-2016

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Date of assessment

- -

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SECTION 1. GENERAL INFORMATION

WE WOULD LIKE TO START BY ASKING YOU A FEW QUESTIONS ABOUT YOURSELF, YOUR

FAMILY AND YOUR HOME.

1.1 Date of Birth

- -

e.g. 09-Feb-1980

1.3 What is the highest level of qualification that you have?

No formal qualification

GCSE, CSE, O level or equivalent

A-level/AS level or equivalent

Degree level or higher

Other (Please specify)

1.4 At what age did you complete your continuous full time education?

Yeas ______ Never went to school ________

1.5 What is your CURRENT legal marital or civil partnership status?

Married or in a registered civil partnership

Separated, but still legally married or in a civil partnership

Divorced or formerly in a civil partnership which is now legally dissolved

Widowed or surviving partner from a civil partnership

Never married and never registered in a civil partnership

1.6 How many adults, aged 18 years or over live in the same household as

you? (Apart from yourself - put zero if there are no other adults.)

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1.7 How many children live in the same household as you?

(Put zero if there are none.)

1.8 How many children do you have? Please include all children that you

consider to be part of your family.

1.9 How old are your children?

Please add the number of children of each age group.

Preschool age

Primary - Reception, School Year 1& 2

Primary – School Year 3-6

Secondary school- School Year 7-11

College/ Sixth Form

Age 18+

1.10 What is your current or most recent paid job title?……………………………

1. 11 Which of these best describes your current work situation? (Please tick

all that apply)

In paid work (full or part-time including self-employed)

Unemployed/looking for work

Retired from paid work

Looking after the family or home

Unable to work because of a long term health problem

In full-time education or training

Other (If other please

describe)...............................................................................................

Father’s baseline questionnaire V2.0: 22-11-2016

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1.12 Which of these best describes your religion None Hinduism/Hindu

Christian (including Church of England, Judaism/Jewish Catholic, Protestant, Methodist, Baptist and all other Christian denominations)

Buddhism/Buddhist Islam/Muslim Sikhism/Sikh Any other religion (Please write in) Jehovah’s Witness I do not wish to answer.

1.13 What is your main spoken language?

English Pashtu Bengali Sylheti Gujarati Tamil Hindi Urdu Punjabi Polish Patois/ Creole Romanian

Hungarian Lithuanian

Other (please write in)

Father’s baseline questionnaire V2.0: 22-11-2016

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SECTION 2. INTERNATIONAL PHYSICAL ACTIVITY QUESTIONNAIRE The IPAQ can be found at: https://sites.google.com/site/theipaq/

SECTION 3. YOUR FOOD AND DRINK INTAKE

What type of fruit/vegetables did you eat yesterday?

(include how much, i.e. piece of fruit, tablespoon, handful, bowlful or glass of fruit juice)

What fruit or vegetable

How much? tablespoon

handful

piece

bowl

glass

Example = peas

2

Father’s baseline questionnaire V2.0: 22-11-2016

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What type of milk do you usually drink?

How many pieces of fruit do you usually eat? (include all types including dried and tinned fruit)

Normal full fat milk None

Semi-skimmed milk Less than 1 per week

Skimmed milk 1-2 per week

Soy milk 3-4 per week

Rice milk 5-6 per week

Not sure Once per day

I don’t drink milk 2-3 per day

4 or more per day

How many times a week do you eat vegetables or salad with your meal at night? (not including chips or potatoes)

How often do you eat takeaway foods? e.g. Chinese, Indian, fish and chips, burger, kebab, pizza.

Never Never

Less than once per week Less than once per week

1-2 per week 1-2 per week

3-4 per week 3-4 per week

5 or more per week 5-6 per week

Once a day

1 or more per day

How many times a week do you eat your meal at night in front of the television?

Add up how many glasses of soft drink, squash or cordial you have each day? (all types except juice)

Never Never

Less than once per week Less than 1 per day

1-2 per week 1 per day

3-4 per week 2-3 per day

5-6 per week 4-6 per day

Every day 7 or more per day

How often do you have fruit juice-based drinks e.g. orange juice

How many times a day do you eat snacks (any type)?

Never Less than 1 per day

Less than 1 per month 1-2 per day

1-3 per month 3-4 per day

1 per week 5-6 per day

2-6 per week 7 or more per day

1 per day

Father’s baseline questionnaire V2.0: 22-11-2016

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2 or more per day

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Do you ever drink alcohol?

No, please go to SECTION 4 – Your General Health

Yes, please continue to next question

When answering the next 3 questions, please convert the amounts you drank into glasses using the examples below. For spirits, liqueurs and mixed drinks containing spirits, please count each shot (30mls) as one glass.

I can of beer = 2 units 1 bottle of wine (750mls) = 6 glasses

I large bottle of beer (750mls) = 4 glasses 1 bottle of port/ sherry (750mls) = 12 glasses

Over the last 3 months, how many days of the week did you consume alcohol?

Over the last 3 months, on the days of the week when you were drinking, how

many glasses of beer, wine and/or spirits did you usually drink?

Total number of glasses per day 1 2 3 4 5 6 7 8 9 10 or

more

Over the last 3 months, what was the maximum number of glasses of beer,

wine and/or spirits that you drank in 24 hours?

Total number of glasses per 24 hours

1-2 3-4 5-6 7-8 9-10 11-12 13-14 15-16 17-18 19 or more

Total number of days of alcohol consumed

1 2 3 4 5 6 7 8 9 10 or more

Father’s baseline questionnaire V2.0: 22-11-2016

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SECTION 4. YOUR GENERAL HEALTH

EUROQOL The EQ-5D-5L

This can be obtained from:

https://euroqol.org/wp-content/uploads/2016/10/Sample_UK__English__EQ-5D-

5L_Paper_Self_complete_v1.0__ID_24700.pdf

ICECAP-A measure v2

This can be obtained from:

https://www.birmingham.ac.uk/research/activity/mds/projects/HaPS/HE/ICECAP/ICE

CAP-A/index.aspx

SECTION 5. FAMILY PHYSICAL ACTIVITY, SCREEN USE AND EATING PATTERNS

Physical activity modelling subscale of the Activity Support scale (5 items).

Reference: Davison KK, Li K, Baskin ML, Cox T, Affuso O. Measuring parental support

for children’s physical activity in white and African American parents: the Activity

Support Scale for Multiple Groups (ACTS-MG). Prev Med. 2011;52:39–43

Parenting strategies for eating and activity scale (PEAS) (7 items)

Reference for the original questionnaire: Larios SE, Ayala GX, Arredondo EM,

Baquero B, Elder JP. Development and validation of a scale to measure Latino

parenting strategies related to children’s obesigenic behaviors. The parenting

strategies for eating and activity scale (PEAS). Appetite. 2009;52:166–172.

Reference: Gattshall, M. L., Shoup, J. A., Marshall, J. A., Crane, L. A., & Estabrooks, P. A. (2008). Validation of a survey instrument to assess home environments for physical activity and healthy eating in overweight children. International Journal of Behavioral Nutrition & Physical Activity, 5, 1-13.

Father’s baseline questionnaire V2.0: 22-11-2016

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Food During the past 7 days, how many times did all of your household eat together

at: (Please enter single figure e.g. 3)

Breakfast: _____________(answer 0 to 7)

Lunch: _____________(answer 0 to 7)

Dinner: _____________(answer 0 to 7)

Father-child relationship

Father involvement using the Parent-Child Relationships Questionnaire (five

factors: personal relationship–companionship and intimacy, warmth–nurturance and

affection, disciplinary warmth–praise, prosocial behaviours and shared decisions

making, power assertion—quarrelling and forceful punishment and possessiveness–

control and protectiveness

Reference: Furman, W., & Gilberson, R. (1995). Identifying the links between

parents and their children's sibling relationships. In S. Shulman (Ed.), Close

relationships in social-emotional development. Norwood, NJ: Ablex.

SECTION 6. YOUR USE OF HEALTH SERVICES 6.1 How many times have you consulted the following healthcare professionals regarding your health during the past 3 months?

GP

times

Practice nurse

times

Pharmacist

times

6.2 In the last 12 months have you been admitted to hospital (spent at least

one night)?

Yes No If no, please go to question 6.4

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6.3 If yes how many times? (please use table provided to

help you)

admissions in last 12 months

total nights spent in hospital

6.4 During the last 12 months did you ever attend as a patient at the casualty

or A&E department of a hospital?

Yes No If no, please go to 6.6

6.5 If yes, how many times?

times in the last 12 months

6.6 During the last 12 months did you ever attend as a patient to an outpatient

appointment at a hospital?

Yes No If no, you have completed this questionnaire

6.7 If yes, how many times?

times in the last 12 months

Thank you for completing this questionnaire

Admission No. of

nights

1st

2nd

3rd

Total

Children’s baseline questionnaire V2.0 22-11-2016

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Children’s QUESTIONNAIRE

Baseline

Father ID

Child ID

Child initials

Resident with

father

Yes No

Researcher name

Date of

assessment

- -

Children’s baseline questionnaire V2.0 22-11-2016

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FOOD AND DRINK

Please tick one box for each question. Parents, if your child is unable to complete the questionnaire themselves, please complete it on their behalf

What type of milk does your child usually drink?

How many pieces of fruit does your child usually eat? (include all types)

Normal full fat milk None

Semi-skimmed milk Less than 1 per week

Skimmed milk 1-2 per week

Soy milk 3-4 per week

Rice milk 5-6 per week

Not sure Once per day

I don’t drink milk 2-3 per day

4 or more per day

How many times a week does your child eat vegetables or salad with your meal at night? (not including chips)

How often does your child eat takeaway foods? e.g. Chinese, Indian fish and chips, burger, kebab, pizza.

Never Never

Less than once per week Less than once per week

1-2 per week 1-2 per week

3-4 per week 3-4 per week

5 or more per week 5-6 per week

Once a day

1 or more per day

How many times a week does your child eat your meal at night in front of the television?

Add up how many glasses of soft drink, squash or cordial your child has each day? (all types except juice)

Never Never

Less than once per week Less than 1 per day

1-2 per week 1 per day

3-4 per week 2-3 per day

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5-6 per week 4-6 per day

Every day 7 or more per day

How often does your child have fruit juice-based drinks e.g. orange juice

How many times a day does your child eat snacks?

Never Less than 1 per day

Less than 1 per month 1-2 per day

1-3 per month 3-4 per day

1 per week 5-6 per day

2-6 per week 7 or more per day

1 per day

2 or more per day

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What type of fruit/vegetables did you (your child) eat yesterday?

(include how much, i.e. piece of fruit, tablespoon, handful, bowlful or glass of

fruit juice)

Child:

What fruit or

vegetable

How much?

tablespoon

handful

piece

bowl

glass

e.g. peas

2

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SECTION 2. CHU-9D

The CHU-9D is available from: https://www.sheffield.ac.uk/scharr/sections/heds/mvh/paediatric

For an adult to complete about their eldest child (taking

part in the study):

SECTION 3. Family Nutrition & Physical Activity Screening tool

The FNPA is avai lable from: http:/ /www.myfnpa.org/

[The FNPA Tool was developed at Iowa State University by Michelle Ihmels and Greg Welk in partnership with the American Dietetics Association.]

SECTION 4. YOUR CHILD’S USE OF HEALTH SERVICES

4.1 How many times have you/your partner consulted the following health care

personnel regarding your child’s health during the past 3 months?

GP

times

Practice nurse

times

Pharmacist times

4.2 In the last 3 months has your child been admitted to hospital (spent at least one

night)?

Yes No If no, please go to question 4.4

4.3 If yes how many times? (please use table provided to help

you)

admissions in last 3 months

total nights spent in hospital

Admission No. of

nights

1st

2nd

3rd

Total

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4.4 During the last 3 months did your child ever attend as a patient at the casualty or

A&E department of a hospital?

Yes No If no, please go to 4.6

4.5 If yes, how many times?

times in the last 3 months

4.6 During the last 3 months did your child ever attend as a patient to an outpatient

appointment at a hospital?

Yes No If no, you have finished this questionnaire

4.7 If yes, how many times?

times in the last 3 months

Thank you for completing this questionnaire

D D M M M Y Y Y Y