Evaluation of an Intervention to Increase Cancer Screening in Primary Clinics-Pre Intervention Only

Patient Pre-Intervention Survey

Clinical Care and Health Survey:

Patient Opinions

We are interested in your opinions and experiences you’ve had with your doctor or health care provider talking about colon cancer. This may have included a talk about colon cancer screening tests. We would like to know how you feel about talking with your clinician about these issues. Your opinions are important to us!

Filling in this survey will help us design programs to help your clinician and others give better patient care. You may be contacted one more time in the future so that we can learn more about the opinions and experiences you’ve have talking to your doctor about colon cancer.

 Selected patients 50 years old and older who are active members of [this HMO] are being sent this survey. You are being paid $10 to compensate your for your time and effort.

 Your answers are strictly private

 Your name is not included on your survey

 Answers from other patients like you will be combined into one final summary

 Some questions are personal, but provide important information for this study

 It is your choice to skip any questions that you do not want to answer

 Your doctor will not see your answers

 Filling in this survey can only improve patient care

We thank you very much for taking your time to fill in this survey for us. When you are done, please mail it back to us in the enclosed envelope. Thank you!

CDC LOGO

Centers for Public Health Research and Evaluation

1100 Dexter Avenue N., Suite 400 Seattle, Washington 98109

This survey has questions that come in different forms. When any question asks about “your clinician”, it means the doctor or medical practitioner who last gave you a routine check-up. You will need to write in or check () what you think is the best answer. Please see examples below.

Some questions look like this:

1. What is your age? _________________

2. Are you: 1 Male 2 Female?

You will need to write in or check () the answer.

Some questions ask you to rate your feelings. Please think about how you feel about each of the topics.

For example, the questions look like this:

3. How satisfied were you with…..
Neither
Very Satisfied Nor Very

Dissatisfied Dissatisfied Dissatisfied Satisfied Satisfied

b. the doctor’s explanation of the     

screening procedure

Please check () the answer that best shows how you feel.

Some questions ask you to give us your opinions. Please think about if you disagree or agree about each of the statements that you read.

For example, the questions look like this:

Neither
Strongly Agree nor Strongly

Disagree Disagree Disagree Agree Agree

C. Men get colon cancer more often than     

Women

Please check () the answer that best shows how strongly you disagree or agree.

Patient Questionnaire

Part I: Tell Us About Yourself

This section asks questions to let us describe patients who take part in the survey. Please answer the following questions. Please write or check () the best answer.

1. What is your age? ____________

2. What is your sex?  Male  Female

3. Do you consider yourself: (Select () one)

 Hispanic or Latino

 Not Hispanic or Latino

4. What is your race? (Select () one or more)

 White

 Black or African American

 Asian

 American Indian or Alaska Native

 Native Hawaiian or Other Pacific Islander

5. What language do you usually speak at home?

 English  Spanish  Other (Please specify) ___________________

6. Are you employed?  Yes  No

If Yes: Is it  Full Time?  Part Time?

7. What was your total family income (before taxes) from ALL income sources in your household in the last year? (Please check () the one that is your best guess).

 Less than $10,000  $35,000 to $49,000

 $10,000 to $19,000  $50,000 to $74,000

 $20,000 to $34,000  $75,000 +

 Don’t know

8. What is the highest grade or year of school you finished?

 Didn’t go to school

 Grade School (1-5 years)

 Middle school (6-8 years)

 Some High School (9-11 years)

 High school diploma or G.E.D.

 Vocational or training school

 Some college or Associate Arts Degree

 College graduate with BA or BS Degree

 Graduate/professional education and/or Degree

Now we would like to ask you about your relationship with your doctor. Please write in or check () the best answer. If a question asks about “this doctor”, it means the doctor or clinician who gave you your annual check-up (i.e., annual exam, yearly physical exam).

9. How long have you been a patient with the doctor who did your last annual check-up? _____________

9. How would you describe how often you have seen this doctor?

(Please check () all that apply).

 I am a new patient of this doctor and I have only visited once or twice.

 I get most of my care from this doctor.

 This doctor does most of my annual check-ups.

 I get most of my care from another doctor or nurse in this doctor’s office.

 I get most of my care from another doctor’s or nurse’s office.

 Other (Please specify) _________________________________

11. How many times in the past year have you seen this doctor? ____________

12. Which type of health coverage do you have in your health plan? (Check () all that apply)

 Co-pay less than or equal to $10 for all clinic visits

 Co-pay between $10 and $20 for all clinic visits

 Free (no cost) annual exam visit

 Co-pay for annual exam visit

 Free (no cost) preventive services (screening for cholesterol, blood sugar, cervical cancer, colorectal cancer, breast cancer, prostate cancer)

 Co-pay for all preventive services (screening for cholesterol, blood sugar, cervical cancer, colorectal cancer, breast cancer, prostate)

Part II: Personal Cancer Experience and
Family History of Colon Cancer

Please answer the following questions about colon cancer. When we use the term colon cancer, we mean cancer of the colon, rectum, or bowel. You may also have heard the term colorectal cancer. Please write in or check () the best answer.

1. How likely do you think you are to develop colon cancer sometime in your life?

Would you say it is…

 Extremely unlikely  Unlikely  Neither likely or unlikely  Likely  Extremely likely

2. Compared to other people your age how would you rate your own risk of getting colon cancer?

 Much lower  Lower  About the same  Higher  Much higher

3. In general, would you say that your health is….

 Excellent  Very good  Good  Fair  Poor

4. Have you ever been diagnosed with cancer?

 Yes  No (go to question 5)

If ‘Yes’, what type of cancer? __________________________________

5. Has anyone in your immediate family (i.e., spouse, children, parents, siblings) ever been diagnosed with cancer?

 Yes  No or Don’t Know (Go to Part III, Question 1)

If ‘Yes’, please list your immediate family members who have had cancer and the type of cancer. List up to 5 family members.

Family Member	Type of Cancer
1._________________________	_________________________
2._________________________	_________________________
3._________________________	_________________________
4._________________________	_________________________
5._________________________	_________________________

Part III: Experience with Tests and Screenings

Now we are interested in your experience with colorectal cancer screening or testing. Please answer the following questions about colon cancer and colon cancer screening tests.

1. Have you ever had any bowel symptoms (i.e., blood in the stool, changes in bowel movements) that prompted your doctor to suggest you be tested for colon cancer?

 Yes  No

2. Have you heard of the following tests for colon cancer?

	Yes	No
Digital rectal exam		
Fecal occult blood test (FOBT) or Hemoccult test (stool card test)		
Flexible sigmoidoscopy		
Colonoscopy		
Barium enema		

3. How worthwhile do you think the following tests are for detecting colon cancer early?

(Please mark “Don’t Know” if you have never heard of the test)

	Not at all worthwhile	Slightly worthwhile	Somewhat worthwhile	Quite worthwhile	Very worthwhile	Don’ t Know
Digital rectal exam						
Fecal occult blood test (FOBT) or Hemoccult (stool card test)						
Flexible sigmoidoscopy						
Colonoscopy						
Barium enema						

4. Please check () below if your doctor did or ordered the following tests at your last check-up AND / OR some other time in the last five years.
Tests ordered:	Done or Ordered at last Check-up?  answer		Done or Ordered in the last 5 years?  answer
	Yes	No	Yes	No
Blood pressure				
Cholesterol test (blood test)				
Digital rectal exam for colon cancer (i.e., ‘finger’ test)				
FOBT (stool card test)				
Flexible sigmoidoscopy				
Colonoscopy				
For Women:
Pap smear				
Breast exam				
Mammogram (breast x-ray)				
For Men:
Prostate specific antigen blood test (PSA)				

5. Please check () below if your doctor talked to you about each issue at your last check-up AND / OR anytime in the last five years.
Did your doctor talk to you about:	Talked about at last check-up?			Talked about in the last 5 years?			IF TALKED ABOUT: Who brought the subject up?
	Yes	No	NA	Yes	No	NA	Me	Doctor	NA
Smoking									
Exercise or physical activity									
Your dietary practices									
Breast cancer screening									
Cervical cancer screening									
Prostate cancer screening									
Colorectal cancer screening									
Fecal occult blood test (FOBT)									
Flexible sigmoidoscopy									
Colonoscopy									

Part IV: Colon Cancer Screening Experience

Now we are interested in your experience with either FOBT, Flexible Sigmoidoscopy or Colonoscopy.

FOBT stands for a Fecal Occult Blood Test which is a set of cards to take home to collect a stool sample. Then you mail in or return the cards to be tested for hidden blood in the stool. (Sometimes called Hemoccult test or stool card test)

Flexible Sigmoidoscopy is also called a ‘Flex Sig’. It is when a doctor or nurse practitioner inserts a flexible tube into your rectum (or bottom) to check for bowel problems and colon cancer.

A Colonoscopy is a medical procedure which you will have in a clinic or hospital setting. It allows a full viewing of the colon. You will have preparation that you will do, and during the procedure you will be given a sedative. A doctor inserts a flexible tube into your rectum (or bottom) to check for bowel problems and colon cancer.

1. Please check whether and when you have had each of the following colon cancer screening tests. (Please check () only one box for each test).

	Never had screening	Less than 6 months ago	6 months to a year ago	1-2 years ago	3-5 years ago	6-10 years ago	More than 10 years ago
FOBT							
Flex Sig							
Colonoscopy							
Barium Enema							

Fecal Occult Blood Test (FOBT)

2. Have you been given an FOBT kit to take home in the last year?

 Yes  No (If No, go to Question 9)

3. Were you given instructions on how to use the FOBT cards?

 Yes  No

4. Were you reminded to return the cards?

 Yes  No

5. Did you return the cards?

 Yes  No If No, Why not? _____________________________________

6. Did you get the results?  Yes  No

7. How did you get the results?

Phone call from:  physician  nurse  medical assistant

Letter from:  physician  clinic  lab

8. Please check () the best answer below:
How satisfied were you with…..	Very Dissatisfied	Dissatisfied	Neither Satisfied nor Dissatisfied	Satisfied	Very Satisfied
a. Colon cancer information given by your doctor’s office					
b. The doctor’s explanation of the procedures to do the FOBT test					
c. Dietary restrictions					
d. Overall preparations for the FOBT					
e. Collection of the stool sample					
f. Reminder procedures					
g. Follow-up procedures					
h. Explanation of the FOBT test results					
i. Receiving the FOBT test results					

Flexible Sigmoidoscopy (Flex Sig) (Please see the definition on page 6)

9. In the past 5 years did your doctor recommend a Flex Sig test?

 Yes  No (If No, go to Question 14)

10. Did you schedule an appointment?

 Yes  No If No, Why not? _________________________________________

11. Did you have the test?

 Yes  No If No, Why not? _________________________________________

12. Did you get the results?  Yes  No

13. Please check () the best answer below:
Flex Sig How satisfied were you with…..	Very Dissatisfied	Dissatisfied	Neither Satisfied nor Dissatisfied	Satisfied	Very Satisfied
a. Colon cancer information given by your doctor					
b. The doctor’s explanation of the Flex Sig screening test					
c. Dietary restrictions					
d. The use of an enema or laxatives					
e. Overall preparations for the Flex Sig					
f. The convenience of the screening location					
g. How the screening technician treated me					
h. The level of discomfort during the Flex Sig procedure					
i. Follow-up procedures					
j. Explanation of the Flex Sig test results					

Colonoscopy (Please see the definition on page 6)

14. In the past 10 years did your doctor recommend a Colonoscopy test?

 Yes  No (If No, skip to next section)

15. Did you schedule an appointment?

 Yes  No If No, Why not? _________________________________________

16. Did you have the test?

 Yes  No If No, Why not? _________________________________________

17. Did you get the results?  Yes  No

18. Please check () the best answer below:
How satisfied were you with…..	Very Dissatisfied	Dissatisfied	Neither Satisfied nor Dissatisfied	Satisfied	Very Satisfied
a. Colon cancer information given by your doctor					
b. The doctor’s explanation of the Colonoscopy screening test					
c. Dietary restrictions					
d. The use of an enema or laxatives					
e. Overall preparations for the Colonoscopy					
f. The convenience of the screening location					
g. How the screening technician treated me					
h. The level of discomfort during the Colonoscopy procedure					
i. Follow-up procedures					

Part V: Colon Cancer Knowledge

1. For each of the following statements please check if you “disagree”, “agree” or are “not sure”.

	Disagree	Agree	Not Sure
a. Eating foods high in fat increases your risk of developing colon cancer.			
b. Your chances of getting colon cancer are greater if you have a family member who had colon cancer.			
c. Men get colon cancer more often than women.			
d. If a person gets colon cancer, it cannot be cured.			
e. Blood in your stool means you have cancer for sure.			
f. A diet with a lot of roughage, like fruits, vegetables, and grains, may reduce your chances of getting colon cancer.			
g. You should have your stool tested for hidden blood every year if you are 50 years or older.			

Part VI: Your Opinions

Please check () how strongly you disagree or agree with each opinion below.

1. Discussing colon cancer screening with my doctor:

	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
a. is not necessary because of my age.					
b. is hard to do because my doctor doesn’t think it is important.					
c. is not as important as talking about other health problems I have.					
d. is only needed if I have symptoms.					
e. would just mean that I would have to have more unnecessary tests done.					
f. is not needed because my doctor has already covered all the issues with me.					
g. would take too much time.					
h. would make me uncomfortable.					
i. is something the doctor won’t talk about because my insurance doesn’t cover it.					
j. is hard to do because my doctor is not easy to talk to.					
k. is a waste of time because when I ask questions, the doctor doesn’t have answers.					
l. would be embarrassing.					

Whether or not you have been given an FOBT kit to take home, your opinions are important to us.

Please check () how strongly you disagree or agree with each opinion below.

2. Having an FOBT (fecal occult blood test):

	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
a. is needed only if I have symptoms.					
b. is needed only if there is a family history of colon cancer.					
c. is not needed if I eat a healthy diet.					
d. would only detect cancer after it is too late.					
e. would give me a feeling of control over my health.					
f. is something I am too busy to do.					
g. would protect my health so I can take better care of my family.					
h. is not as important as screening tests for other diseases and cancers.					
i. is not necessary at my age.					
j. would be awful (disgusting) because I have to handle my stool.					
k. is a test I like being able to do in the privacy of my own home.					
l. is not needed if I’ve had it once before.					
m. involves too much hassle because I have to prepare for the test.					
n. is something I don’t know how to do correctly.					
o. is a waste of time because the test is not accurate.					
p. is unnecessary for women because only men are at risk for colon cancer					

Whether or not you have had a Flex Sig, your opinions are important to us.

Please check () how strongly you disagree or agree with each opinion below.

3. Having a Flex Sig (Flexible Sigmoidoscopy) test:

	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
a. is needed only if there is a family history of colon cancer					
b. can prevent me from getting colon cancer by finding and removing polyps that could become cancer					
c. is unnecessary if I have an FOBT					
d. is unnecessary if I have a Colonoscopy					
e. is not needed if I eat a healthy diet					
f. would only detect cancer after it is too late					
g. would give me a feeling of control over my health					
h. is something I am too busy to do					
i. would protect my health so I can take better care of family					
j. is not as important as screening tests for other diseases and cancers					
k. is a hassle because the wait for the appointment is too long					
l. is not necessary at my age					
m. would be embarrassing					
n. would be stressful (frightening, scary)					
o. would be uncomfortable					
p. is not needed if I’ve had it once before					
q. involves too much hassle because I have to prepare for the test					
r. is unnecessary for women because only men are at risk for colon cancer					

Whether or not you have had a Colonoscopy, your opinions are important to us.

Please check () how strongly you disagree or agree with each opinion below.

4. Having a Colonoscopy test:

	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
a. is needed only if there is a family history of colon cancer					
b. can prevent me from getting colon cancer by finding and removing polyps that could become cancer					
c. is unnecessary if I have an FOBT					
d. is unnecessary if I have a Flex Sig					
e. is not needed if I eat a healthy diet					
f. would only detect cancer after it is too late					
g. would give me a feeling of control over my health					
h. is something I am too busy to do.					
i. would protect my health so I can take better care of family					
j. is not as important as screening tests for other diseases and cancers					
k. is a hassle because the wait for the appointment is too long					
l. is not necessary at my age					
m. would be embarrassing					
n. would be stressful (frightening, scary)					
o. would be uncomfortable					
p. is not needed if I’ve had it once before					
q. involves too much hassle because I have to prepare for the test					
r. is unnecessary for women because only men are at risk for colon cancer					

Whether or not you have been given an FOBT kit to take home or had a Flex sig or Colonoscopy, your opinions are important to us.

5. Please check how strongly you disagree or agree with each opinion below:

	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
a. Fitting a flex sig screening test into my schedule is hard					
b. I have trouble taking time off from work to do the flex sig test					
c. Fitting a colonoscopy screening test into my schedule is hard					
d. I have trouble taking time off from work to do the colonoscopy test					
e. Colon cancer screening is a way for doctors and insurers to make money					
f. Medicare pays for flex sig screening					
g. Medicare pays for colonoscopy screening					
h. My insurance or health plan pays for flex sig screening					
i. My insurance or health plan pays for colonoscopy screening					
j. I would do the FOBT kit if my doctor tells me to					
k. I would do the flex sig if my doctor tells me to					
l. I would do the colonoscopy if my doctor tells me to					
m. My doctor never talks about colon cancer screening					
n. My doctor never talks about FOBT					
o. My doctor never talks about flex sig					
p. My doctor never talks about colonoscopy					

Part VII: Social Support

Please check () how strongly you disagree or agree with each opinion below.

1. Discussing colorectal cancer screening with my doctor (the one who did my last check-up) is something that is encouraged by:
	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
a. my spouse or partner					
b. my family					
c. my friends					
d. my doctor or nurse					
e. the popular media (TV, radio, magazines)					

2. My having an FOBT is something that is encouraged by:
	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree		Strongly Agree
a. my spouse or partner					
b. my family					
c. my friends					
d. my doctor or nurse					
e. the popular media (TV, radio, magazines)					

3. My having a screening flex sig is something that is encouraged by:
	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree		Strongly Agree
a. my spouse or partner					
b. my family					
c. my friends					
d. my doctor or nurse					
e. the popular media (TV, radio, magazines)					

4. My having a screening colonoscopy is something that is encouraged by:
	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree		Strongly Agree
a. my spouse or partner					
b. my family					
c. my friends					
d. my doctor or nurse					
e. the popular media (TV, radio, magazines)					

Part VIII: Plans to Talk About Colon Cancer or Get Screened

Please check () how strongly you disagree or agree with each opinion below.

1. Please answer the following questions about cancer screening:
	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
a. I plan to discuss colon cancer screening with my doctor at my next check-up.					
b. I plan to do an FOBT after my next check-up.					
e. I plan to have a flexible sigmoidoscopy after my next check-up.					
d. I plan have a colonoscopy after my next check-up.					

The End

Thank you very much for completing your survey

Please place it in the enclosed, stamped, envelope and drop it in the mail for us!