Lifetime of Good Health Survey

Evaluation of Office on Women's Health Publications

EvaluationofWomensHealthLifetime of Good Health Survey - OWH Publications 7.12.07

Lifetime of Good Health Survey

OMB: 0990-0319

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Form Approved

OMB No. 0990-XXXX

Exp. 07-XX-2008


Lifetime of Good Health – Feedback Survey


Thank you for taking the time to complete this Participant Feedback Survey for the Lifetime of Good Health: Your Guide to Staying Healthy (The Guide). Please keep in mind that all survey responses are anonymous. Your honest responses will help the Office on Women’s Health improve their current materials and create new materials for women.


Please answer the following questions about the Lifetime of Good Health Guide:

  1. How did you receive a copy of the Guide?

Community health fair Internet Doctor Nurse

Professional conference or event Class/Workshop Lactation Consultant

Peer Counselor National Women’s Health Information Center

Other (please specify):­­_____________ __________________________________

  1. How much of the Guide did you read?

Little or none Less than half More than half Almost all or all

  1. Did you like the Guide?

No, not at all No, not very much Yes, somewhat Yes, very much

  1. How attractive was the format or design of the Guide (i.e. color, pictures, font)?

Not at all attractive Not very attractive Somewhat attractive Very attractive

  1. How useful was the Guide?

Not at all useful Not very useful Somewhat useful Very useful

  1. How does the Guide compare to other health information materials you have read?

Not as good Better than most About the same

I have not received any other general health information

  1. Would you recommend the Guide to a friend or family member?

No, definitely not No, probably not Yes, probably Yes, definitely

  1. I chose to read the Guide because (check all that apply):

I had specific health questions

I wanted to learn more about my health in general

A health care provider recommended it

A friend or family member recommended it

Other:







According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990- . The time required to complete this information collection is estimated to average ( hours)(minutes) per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/ocio/PRA, 200 Independence Ave., S.W., Suite 531-H, Washington D.C. 20201, Attention: PRA Reports Clearance Officer. Alice Bettencourt






Please circle the answer to the questions below that best matches how much you agree or disagree with the following statements? When responding to each item, use a scale from 1 (Strongly Disagree) to 4 (Strongly Agree).

As a result of reading the Lifetime of Good Health Guide…

Strongly Disagree

Disagree

Agree

Strongly Agree

  1. I have thought more about my health in general.

1

2

3

4

  1. I have a greater understanding of the importance of my health.

1

2

3

4

  1. I plan to learn more about my health.


1

2

3

4

  1. I feel more confident in my ability to lead a healthy life.

1

2

3

4

  1. I have a better understanding of where I can get health information.

1

2

3

4



Please answer the questions below thinking about what you knew or felt As a result of reading the Guide. When responding to each item, use a scale from 1 (No, not at all) to 4 (Yes, definitely).

As a result of Reading the Guide?

No, Not

At All

Yes,

Definitely

1

2

3

4

  1. I felt motivated to take new steps to improve my health.

1

2

3

4

  1. I felt motivated to talk to my doctor.

1

2

3

4

  1. I felt motivated to get regular screening tests and immunizations.

1

2

3

4

  1. I got regular screening tests and immunizations.

1

2

3

4

  1. I knew my family health history.

1

2

3

4




Circle your response to the following questions.

As a result of reading the Guide…

No

Yes

  1. Do you plan to make an appointment to see a health care provider?

No

Yes

  1. Do you plan to get any screening tests or immunizations?

No

Yes

  1. Do you plan to contact Medicare directly by phone?

No

Yes

  1. Do you plan to review the Medicare website?

No

Yes



On a scale of 1 (No, not at all) to 6 (Yes, Definitely), how much do you agree or disagree with the following statements?


No,

Not at all

Yes,

Definitely

1

2

3

4

  1. The steps provided in the Guide were easy to follow.

1

2

3

4

  1. I was able to find information quickly.

1

2

3

4

  1. I used the Guide to make healthy choices for myself.

1

2

3

4



Please answer the following questions about the specific sections in the Lifetime of Good Health Guide. If you place a check () in Column A, please answer the questions in Columns B and C. If you do NOT place a check () in Column A, please move on to the next Section.

Sections

A. Check (√) the box if you read this section in the Guide


B. How much new information did you learn from reading this section?

C. After you read this section, did you start taking any of the recommended “Steps You Can Take”?

Nothing

At All

A lot

No

Yes

1

2

3

4

  1. Healthy Heart & Stroke Prevention

1

2

3

4

No

Yes

  1. Healthy Bones

1

2

3

4

No

Yes

  1. Breast Cancer Early Detection

1

2

3

4

No

Yes

  1. Healthy Pregnancy

1

2

3

4

No

Yes

  1. Breastfeeding

1

2

3

4

No

Yes

  1. Stress

1

2

3

4

No

Yes

  1. Menopause

1

2

3

4

No

Yes

  1. Reproductive Health

1

2

3

4

No

Yes

  1. Cervical Health

1

2

3

4

No

Yes

  1. Healthy Eyes and Ears

1

2

3

4

No

Yes

  1. Colorectal Health

1

2

3

4

No

Yes

  1. Healthy Lungs

1

2

3

4

No

Yes

  1. Healthy Smile

1

2

3

4

No

Yes

  1. Healthy Skin

1

2

3

4

No

Yes

  1. Urinary Tract Health

1

2

3

4

No

Yes

  1. Violence in Your Life

1

2

3

4

No

Yes

  1. Healthy Weight

1

2

3

4

No

Yes

  1. Diabetes

1

2

3

4

No

Yes

Additional Comments

  1. Please provide additional comments about the Lifetime of Good Health Guide below.








Please answer the following questions about yourself.

A. How often do you get a physical examination from a health care provider?

More than once each year

Once a year

Every 2-3 years

Every 4-5 years

I do not regularly visit a doctor


B. How often do you get a pap smear? [A pap smear is a test given by a gynecologist or obstetrician to screen for cervical cancer]

Once a year

Every 2-3 years

Every 4-5 years

I do not regularly get a pap smear


C. How often do you perform a breast self-examination?

Once a month or more

A few times a year

Once a year or less

I do not perform breast self-examinations


D. Please describe your marital status (check ALL that apply):

Single

In a relationship

Married


Separated or divorced

Widowed

Other (please specify):


E. Please check ALL of the following that apply:

I have never been pregnant

I plan to get pregnant

within the next six months

I am currently pregnant

I am the mother of a baby younger than 1 yr. old

I am the mother of a child older than 1 yr. old

None of the above

F. How many children do you have?

0

1

2

3

4

5 or more


G. How old are you? Under 18 yrs 25-29 yrs 40-49 yrs 60-69 yrs

18–24 yrs 30-39 yrs 50-59 yrs 70+ yrs

I. What is your race? (Check ALL that apply.)


o Black/African American

o White/Caucasian

o Hispanic or Latino

o American Indian or Alaska Native

o Native Hawaiian or other Pacific Islander

o Asian


J. What is the highest level of education that you have completed?

Part of high school

High school graduate / GED

Part of college / university

College / university graduate

Graduate school

K. For how much of this past year have you had health insurance?

  • I have had health insurance for the entire year.

  • I have had health insurance for part of the year.

  • I did NOT have any health insurance during the past year.

M. In what city and state do you live? ___________________________ _________

City State

N. Are you?  Female  Male

O. Are you a health care provider or health educator?  No  Yes


Thank you for taking the time to complete this survey.

Prepared by Shattuck & Associates, Inc. 5/21/2007

File Typeapplication/msword
File TitleLearning About Learning Questionnaire
AuthorJana
File Modified2007-07-12
File Created2007-07-12

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