SoutheastHEALTH Community Health Needs Assessment (CHNA) Survey

1
SoutheastHEALTH is conducting a Community Health Needs Assessment. As part of that assessment, research is gathered from the community through this survey. You will be providing information needed to identify and prioritize community health concerns in your community. The information will be used to discover where improvements can be made to create a healthier environment for you and your family. This survey will take approximately 15-20 minutes to complete. Please only respond to this survey if you are at least 18 years of age and live in the counties of Cape Girardeau, Bollinger, Scott or Stoddard in Missouri. Do not include your name or any identifiers on the survey. Only one survey should be completed per household. All survey respondents will remain anonymous.

After completing the survey, there will be an option to enter a drawing for one of twenty five $25 VISA gift cards. The drawing will be a separate form where you can provide your name and contact information. This information will not be tied back to your survey response.

Thank you for your cooperation and participation!
2
Please select the county in which you live:* This field is required.
Bollinger County, MO
Cape Girardeau County, MO
Scott County, MO
Stoddard County, MO
Other
3
What is your 5-digit zip code? * This field is required.
4
What is your age?* This field is required.
18-24
25-34
35-44
45-54
55-64
65+
5
What is your marital status?* This field is required.
Single
Married
Living with Partner
Divorced
Widowed
6
What is your sex?* This field is required.
Male
Female
7
What is your race/ethnicity?* This field is required.
Asian or Pacific Islander
Black or African American
Hispanic or Latino
Native American or Indigenous
White or Caucasian
Two or more races
8
How many people currently live in your household?* This field is required.
1-2
3-5
6 or more
9
How many adults aged 65 years or older currently live in your household?* This field is required.
None
1-2
3-5
6 or more
10
How many children under 18 years of age currently live in your household?* This field is required.
None
1-2
3-5
6 or more
11
Select all that describe your home or household.* This field is required.
Have more than 1 working smoking detector
Have a carbon monoxide monitor
Food is put back in the refrigerator within 2 hours after a meal
Have a septic tank
Have pets (dogs, cats, reptiles, etc)
Have internet access
Provide care for an older adult
Have children under 13 that are unsupervised in non-school hours
12
What is your highest level of education?* This field is required.
Never graduated high school
High school diploma or GED
Currently attending or have some college
Two-year college degree
Four-year college degree
Graduate-level degree or higher
13
What is your employment status? Check all that apply.* This field is required.
Employed
Student
Homemaker
Retired
Unemployed
Disabled
14
What is your annual household income?* This field is required.
Less than $5,000
$5,000 to $14,999
$15,000 to $24,999
$25,000 to $49,999
$50,000 to $74,999
$75,000 to $99,999
$100,000+
15
What sources do you use to obtain most of your health-related information? Check all that apply.* This field is required.
Family/Friends
Doctor/Nurse/Pharmacist
Newspaper/Magazines/Television
Health Department
Church
School
Internet
16
In the following section, respond with how often YOU do the following: (*N/A = does not apply to you)* This field is required.
N/A
Never
Sometimes
Almost Always
Always
Exercise at a moderate pace at least 30 minutes per day, 5 days per week
Consume more than 3 alcoholic beverages per day (female) or more than 5 per day (male)
Smoke cigarettes
Use e-cigarettes/vapor
Are exposed to secondhand smoke at home or in the workplace
Chew tobacco
Use illegal drugs (marijuana, cocaine, methamphetamine, heroin, and/or other opioids)
Exercise at a moderate pace at least 30 minutes per day, 5 days per week
Consume more than 3 alcoholic beverages per day (female) or more than 5 per day (male)
Smoke cigarettes
Use e-cigarettes/vapor
Are exposed to secondhand smoke at home or in the workplace
Chew tobacco
Use illegal drugs (marijuana, cocaine, methamphetamine, heroin, and/or other opioids)
N/A
Never
Sometimes
Almost Always
Always
N/A
Never
Sometimes
Almost Always
Always
N/A
Never
Sometimes
Almost Always
Always
N/A
Never
Sometimes
Almost Always
Always
N/A
Never
Sometimes
Almost Always
Always
N/A
Never
Sometimes
Almost Always
Always
N/A
Never
Sometimes
Almost Always
Always
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In the following section, respond with how often YOU do the following: (*N/A = does not apply to you)* This field is required.
N/A
Never
Sometimes
Almost Always
Always
Get a flu shot each year
Practice safe sex (use of condom or other barrier method)
Get enough sleep each night (7-8 hours)
Eat at least 5 servings of fruits and vegetables each day
Eat fast food at least once per week
Feel stressed out or unhappy about your life
Apply sunscreen when spending time outside
Get a flu shot each year
Practice safe sex (use of condom or other barrier method)
Get enough sleep each night (7-8 hours)
Eat at least 5 servings of fruits and vegetables each day
Eat fast food at least once per week
Feel stressed out or unhappy about your life
Apply sunscreen when spending time outside
N/A
Never
Sometimes
Almost Always
Always
N/A
Never
Sometimes
Almost Always
Always
N/A
Never
Sometimes
Almost Always
Always
N/A
Never
Sometimes
Almost Always
Always
N/A
Never
Sometimes
Almost Always
Always
N/A
Never
Sometimes
Almost Always
Always
N/A
Never
Sometimes
Almost Always
Always
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In the following section, how often do any children 18 or under CURRENTLY living in your home do the following? *(N/A = does not apply to them)* This field is required.
N/A
Never
Sometimes
Almost Always
Always
Participate in at least 1 hour of physical activity every day
Are exposed to secondhand smoke in the home
Get a flu shot each year
Practice safe sex (condom or other barrier methods)
Get enough sleep each night (7-9 hours)
Eat at least 5 servings of fruits and vegetables each day
Eat fast food more than once per week
Limit screen time (TV, smart phone, tablets, computer, video games) to 2 hours or less each day
Drink sugar sweetened drinks (soda, Gatorade, juice with added sugar, energy drinks)
Apply sunscreen before planned time outside
Participate in at least 1 hour of physical activity every day
Are exposed to secondhand smoke in the home
Get a flu shot each year
Practice safe sex (condom or other barrier methods)
Get enough sleep each night (7-9 hours)
Eat at least 5 servings of fruits and vegetables each day
Eat fast food more than once per week
Limit screen time (TV, smart phone, tablets, computer, video games) to 2 hours or less each day
Drink sugar sweetened drinks (soda, Gatorade, juice with added sugar, energy drinks)
Apply sunscreen before planned time outside
N/A
Never
Sometimes
Almost Always
Always
N/A
Never
Sometimes
Almost Always
Always
N/A
Never
Sometimes
Almost Always
Always
N/A
Never
Sometimes
Almost Always
Always
N/A
Never
Sometimes
Almost Always
Always
N/A
Never
Sometimes
Almost Always
Always
N/A
Never
Sometimes
Almost Always
Always
N/A
Never
Sometimes
Almost Always
Always
N/A
Never
Sometimes
Almost Always
Always
N/A
Never
Sometimes
Almost Always
Always
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19
What kinds of insurance do you (and/or your family) have currently? Check all that apply.* This field is required.
Health
Dental
Vision
Do not have insurance
20
What type of health insurance do you (and/or your family) have currently? Check all that apply.* This field is required.
Self-insured
Employer-provided
Medicare
Medicaid or MC+
VA
Marketplace
Do not know
Do not have health insurance
Other
21
If anyone in your household does not have insurance, who is NOT currently covered?* This field is required.
Entire Family
At least one adult
All adults
Child(ren) age 6 or older
Child(ren) less than age 6
Does not apply
22
What is your current health status?* This field is required.
Poor
Fair
Good
Very Good
Excellent
23
When was your last regular doctor’s visit?* This field is required.
Within the last 12 months
Within the last 13-18 months
Within the last 19-24 months
Between 2 and 5 years
Over 5 years ago
Never had a routine visit
24
How many days have you been too sick to work or carry out your usual activities during the past 30 days?* This field is required.
None
1-2 days
3-5 days
6-10 days
More than 10 days
25
Have you ever had health issues due to any of the following? Check all that apply.* This field is required.
Alcohol abuse
Lack of pregnancy care
Stress
Drug abuse/addiction
None of the above
26
If you were ever pregnant, did you receive prenatal care?* This field is required.
Yes
No
Not Sure
Does not apply
27
If you ever gave birth to a child, did you breastfeed?* This field is required.
No
Yes, for 6 months or less
Yes, for more than 6 months
Does not apply
28
Where do you go for routine health care? Check all that apply.* This field is required.
Physician’s Office
Hospital Emergency Room
Health Department Clinic
Urgent Care Center
Chiropractor
Community Clinic
Federally Qualified Health Center (i.e. Cross Trails, SEMO Health Network)
Retail Clinic (i.e. Walgreens, CVS)
Do not seek healthcare
29
How often are you able to visit a doctor when needed?* This field is required.
Always
Sometimes
Seldom
Never
30
If you answered seldom or never to the previous question, please choose why you were not always able to visit a doctor when necessary:* This field is required.
No insurance
Too expensive/can’t afford
Could not get an appointment
Lack of transportation
Doctor is too far away/inconvenient location
Other
Does not apply
31
Select any of the following preventative measures you have had in the last year. Check all that apply.* This field is required.
Mammogram
Pap smear
Lung screening
Flu shot
Colonoscopy
Blood pressure check
Skin cancer screening
Prostate cancer screening (PSA test)
Cholesterol screening
STD (sexually transmitted disease) screening
Vision screening
Hearing screening
Cardiovascular screening
Bone density test
Dental exam
Diabetes A1-C check
32
Are you aware of what screenings are needed at what age?* This field is required.
Yes
No
Not sure
33
Are you and any children living in your household up to date on your immunizations?* This field is required.
Yes
No
I am up to date, but my children are not
I am not up to date, but my children are
Do not know
34
Did you and any children living in your household receive the COVID-19 immunization?* This field is required.
Yes
No
I did, but my children did not
I did not, but my children did
Do not know
35
Have you been diagnosed by a doctor with any of the following health problems or diseases? If you have NOT been diagnosed by a doctor with any of these health problems or diseases, please check the “No” box. If you have, please check any boxes that apply to your health problem or disease.* This field is required.
No
Yes, but I am not taking any additional precautions or treatments
Yes, I see a doctor
Yes, I am taking medications or getting treatment
Yes, I feel the disease is well-managed
Diabetes
Stroke
Heart Disease
High Blood Pressure
Coronary Heart Failure
High Cholesterol
Cancer
Asthma
COPD (Chronic Obstructive Pulmonary Disorder)
Kidney Disease
Obesity
Liver Disease
Arthritis
Migraine Headaches
Depression
Bipolar Disorder
Diabetes
Stroke
Heart Disease
High Blood Pressure
Coronary Heart Failure
High Cholesterol
Cancer
Asthma
COPD (Chronic Obstructive Pulmonary Disorder)
Kidney Disease
Obesity
Liver Disease
Arthritis
Migraine Headaches
Depression
Bipolar Disorder
No
Yes, but I am not taking any additional precautions or treatments
Yes, I see a doctor
Yes, I am taking medications or getting treatment
Yes, I feel the disease is well-managed
No
Yes, but I am not taking any additional precautions or treatments
Yes, I see a doctor
Yes, I am taking medications or getting treatment
Yes, I feel the disease is well-managed
No
Yes, but I am not taking any additional precautions or treatments
Yes, I see a doctor
Yes, I am taking medications or getting treatment
Yes, I feel the disease is well-managed
No
Yes, but I am not taking any additional precautions or treatments
Yes, I see a doctor
Yes, I am taking medications or getting treatment
Yes, I feel the disease is well-managed
No
Yes, but I am not taking any additional precautions or treatments
Yes, I see a doctor
Yes, I am taking medications or getting treatment
Yes, I feel the disease is well-managed
No
Yes, but I am not taking any additional precautions or treatments
Yes, I see a doctor
Yes, I am taking medications or getting treatment
Yes, I feel the disease is well-managed
No
Yes, but I am not taking any additional precautions or treatments
Yes, I see a doctor
Yes, I am taking medications or getting treatment
Yes, I feel the disease is well-managed
No
Yes, but I am not taking any additional precautions or treatments
Yes, I see a doctor
Yes, I am taking medications or getting treatment
Yes, I feel the disease is well-managed
No
Yes, but I am not taking any additional precautions or treatments
Yes, I see a doctor
Yes, I am taking medications or getting treatment
Yes, I feel the disease is well-managed
No
Yes, but I am not taking any additional precautions or treatments
Yes, I see a doctor
Yes, I am taking medications or getting treatment
Yes, I feel the disease is well-managed
No
Yes, but I am not taking any additional precautions or treatments
Yes, I see a doctor
Yes, I am taking medications or getting treatment
Yes, I feel the disease is well-managed
No
Yes, but I am not taking any additional precautions or treatments
Yes, I see a doctor
Yes, I am taking medications or getting treatment
Yes, I feel the disease is well-managed
No
Yes, but I am not taking any additional precautions or treatments
Yes, I see a doctor
Yes, I am taking medications or getting treatment
Yes, I feel the disease is well-managed
No
Yes, but I am not taking any additional precautions or treatments
Yes, I see a doctor
Yes, I am taking medications or getting treatment
Yes, I feel the disease is well-managed
No
Yes, but I am not taking any additional precautions or treatments
Yes, I see a doctor
Yes, I am taking medications or getting treatment
Yes, I feel the disease is well-managed
No
Yes, but I am not taking any additional precautions or treatments
Yes, I see a doctor
Yes, I am taking medications or getting treatment
Yes, I feel the disease is well-managed
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36
Have you been diagnosed by a doctor with any of the following health problems or diseases? If you have NOT been diagnosed by a doctor with any of these health problems or diseases, please check the “No” box. If you have, please check any boxes that apply to your health problem or disease.* This field is required.
No
Yes, but I am not taking any additional precautions or treatments
Yes, I see a doctor
Yes, I am taking medications or getting treatment
Yes, I feel the disease is well-managed
Sleep Disorders
Hepatitis
Tuberculosis
Epilepsy/Seizures
Lupus or Autoimmune Disease
Sickle Cell Anemia
Glaucoma
Gonorrhea
HIV/AIDS
Dental Health Problems
Hearing Disorders
Eye/Vision Problems
Sinus Problems
Memory Loss
Sleep Disorders
Hepatitis
Tuberculosis
Epilepsy/Seizures
Lupus or Autoimmune Disease
Sickle Cell Anemia
Glaucoma
Gonorrhea
HIV/AIDS
Dental Health Problems
Hearing Disorders
Eye/Vision Problems
Sinus Problems
Memory Loss
No
Yes, but I am not taking any additional precautions or treatments
Yes, I see a doctor
Yes, I am taking medications or getting treatment
Yes, I feel the disease is well-managed
No
Yes, but I am not taking any additional precautions or treatments
Yes, I see a doctor
Yes, I am taking medications or getting treatment
Yes, I feel the disease is well-managed
No
Yes, but I am not taking any additional precautions or treatments
Yes, I see a doctor
Yes, I am taking medications or getting treatment
Yes, I feel the disease is well-managed
No
Yes, but I am not taking any additional precautions or treatments
Yes, I see a doctor
Yes, I am taking medications or getting treatment
Yes, I feel the disease is well-managed
No
Yes, but I am not taking any additional precautions or treatments
Yes, I see a doctor
Yes, I am taking medications or getting treatment
Yes, I feel the disease is well-managed
No
Yes, but I am not taking any additional precautions or treatments
Yes, I see a doctor
Yes, I am taking medications or getting treatment
Yes, I feel the disease is well-managed
No
Yes, but I am not taking any additional precautions or treatments
Yes, I see a doctor
Yes, I am taking medications or getting treatment
Yes, I feel the disease is well-managed
No
Yes, but I am not taking any additional precautions or treatments
Yes, I see a doctor
Yes, I am taking medications or getting treatment
Yes, I feel the disease is well-managed
No
Yes, but I am not taking any additional precautions or treatments
Yes, I see a doctor
Yes, I am taking medications or getting treatment
Yes, I feel the disease is well-managed
No
Yes, but I am not taking any additional precautions or treatments
Yes, I see a doctor
Yes, I am taking medications or getting treatment
Yes, I feel the disease is well-managed
No
Yes, but I am not taking any additional precautions or treatments
Yes, I see a doctor
Yes, I am taking medications or getting treatment
Yes, I feel the disease is well-managed
No
Yes, but I am not taking any additional precautions or treatments
Yes, I see a doctor
Yes, I am taking medications or getting treatment
Yes, I feel the disease is well-managed
No
Yes, but I am not taking any additional precautions or treatments
Yes, I see a doctor
Yes, I am taking medications or getting treatment
Yes, I feel the disease is well-managed
No
Yes, but I am not taking any additional precautions or treatments
Yes, I see a doctor
Yes, I am taking medications or getting treatment
Yes, I feel the disease is well-managed
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37
How often do you travel outside of your county for medical care?* This field is required.
Always
Sometimes
Seldom
Never
38
If you travel outside of your county for medical care, what services do you seek? Check all that apply.* This field is required.
Medical/doctor appointments – primary care (i.e. family medicine, general wellness, pediatrics)
Medical/doctor appointments – specialty care (i.e. heart, cancer, neurology)
Outpatient treatment
Hospitalization
Dental appointments
Laboratory or other tests
Physical Therapy/Rehabilitation
X-rays, MRIs, other Imaging
Vision appointments
Other
39
If you travel outside of your county for medical care, why? Check all that apply.* This field is required.
Services not available in my county
Better quality elsewhere
Recently moved to this county
Local doctors are not covered by insurance
Closer to work/home
Too hard to get an appointment with a local doctor
Less expensive health care services offered elsewhere
40
Do you feel like there is quality healthcare available in your area?* This field is required.
Yes
No
Do not know
41
Do you feel like there is affordable healthcare available in your area?* This field is required.
Yes
No
Do not know
42
Are there healthcare services that are not available in your area that you would like to see added?* This field is required.
YESNO
43
Please list the services you would like added.
Huge
Large
Normal
Small
Ok
Ok
44
Have you or your family ever been in a situation where you’ve had to choose between eating and paying your bills vs. purchasing needed healthcare and prescription medications?* This field is required.
Yes
No
Do not know
45
Within the past 12 months, did you worry whether your food would run out before you had the money to buy more?* This field is required.
Never true
Sometimes true
Often true
Always true
46
Within the past 12 months, did the food that you bought not last and you did not have the money to buy more?* This field is required.
Never true
Sometimes true
Often true
Always true
47
In this section, please choose how much of a problem you think each item listed is for the county where you live. Do you think each is a serious problem, a moderate problem, not a problem, or are you not sure?* This field is required.
Serious Problem
Moderate Problem
Not a Problem
Not Sure
Ability to afford prescribed medications
Affordable Healthcare
Alcohol Use
Allergies
Ambulance Services
Asthma/Respiratory Disorders
Available Healthcare
Cancer
Drug Use
Eating Disorders
Emergency Preparedness
Fire Protection
Firearms
Fitness Facilities
Healthcare Quality
Heart Disease
High Blood Pressure
HIV/AIDS
Homelessness
Hunger/Food Insecurity
Infant Health
Infectious Diseases (meningitis, hepatitis, COVID-19, etc.)
Job Availability
Ability to afford prescribed medications
Affordable Healthcare
Alcohol Use
Allergies
Ambulance Services
Asthma/Respiratory Disorders
Available Healthcare
Cancer
Drug Use
Eating Disorders
Emergency Preparedness
Fire Protection
Firearms
Fitness Facilities
Healthcare Quality
Heart Disease
High Blood Pressure
HIV/AIDS
Homelessness
Hunger/Food Insecurity
Infant Health
Infectious Diseases (meningitis, hepatitis, COVID-19, etc.)
Job Availability
Serious Problem
Moderate Problem
Not a Problem
Not Sure
Serious Problem
Moderate Problem
Not a Problem
Not Sure
Serious Problem
Moderate Problem
Not a Problem
Not Sure
Serious Problem
Moderate Problem
Not a Problem
Not Sure
Serious Problem
Moderate Problem
Not a Problem
Not Sure
Serious Problem
Moderate Problem
Not a Problem
Not Sure
Serious Problem
Moderate Problem
Not a Problem
Not Sure
Serious Problem
Moderate Problem
Not a Problem
Not Sure
Serious Problem
Moderate Problem
Not a Problem
Not Sure
Serious Problem
Moderate Problem
Not a Problem
Not Sure
Serious Problem
Moderate Problem
Not a Problem
Not Sure
Serious Problem
Moderate Problem
Not a Problem
Not Sure
Serious Problem
Moderate Problem
Not a Problem
Not Sure
Serious Problem
Moderate Problem
Not a Problem
Not Sure
Serious Problem
Moderate Problem
Not a Problem
Not Sure
Serious Problem
Moderate Problem
Not a Problem
Not Sure
Serious Problem
Moderate Problem
Not a Problem
Not Sure
Serious Problem
Moderate Problem
Not a Problem
Not Sure
Serious Problem
Moderate Problem
Not a Problem
Not Sure
Serious Problem
Moderate Problem
Not a Problem
Not Sure
Serious Problem
Moderate Problem
Not a Problem
Not Sure
Serious Problem
Moderate Problem
Not a Problem
Not Sure
Serious Problem
Moderate Problem
Not a Problem
Not Sure
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48
In this section, please choose how much of a problem you think each item listed is for the county where you live. Do you think each is a serious problem, a moderate problem, not a problem, or are you not sure?* This field is required.
Serious Problem
Moderate Problem
Not a Problem
Not Sure
Job Security
Mental Illness
Overweight Adults
Overweight Children
Prenatal Health
Secondhand Smoke
Services for Disabled
Smokeless Tobacco (vaping, e-cigs)
Smoking
Stroke
Suicide
Teen Pregnancy
Transportation to healthcare services
Unemployment
Job Security
Mental Illness
Overweight Adults
Overweight Children
Prenatal Health
Secondhand Smoke
Services for Disabled
Smokeless Tobacco (vaping, e-cigs)
Smoking
Stroke
Suicide
Teen Pregnancy
Transportation to healthcare services
Unemployment
Serious Problem
Moderate Problem
Not a Problem
Not Sure
Serious Problem
Moderate Problem
Not a Problem
Not Sure
Serious Problem
Moderate Problem
Not a Problem
Not Sure
Serious Problem
Moderate Problem
Not a Problem
Not Sure
Serious Problem
Moderate Problem
Not a Problem
Not Sure
Serious Problem
Moderate Problem
Not a Problem
Not Sure
Serious Problem
Moderate Problem
Not a Problem
Not Sure
Serious Problem
Moderate Problem
Not a Problem
Not Sure
Serious Problem
Moderate Problem
Not a Problem
Not Sure
Serious Problem
Moderate Problem
Not a Problem
Not Sure
Serious Problem
Moderate Problem
Not a Problem
Not Sure
Serious Problem
Moderate Problem
Not a Problem
Not Sure
Serious Problem
Moderate Problem
Not a Problem
Not Sure
Serious Problem
Moderate Problem
Not a Problem
Not Sure
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49
50
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