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pdfATTACHMENT A:
Revised Mail Instrument
(changes indicated in yellow)
Dear Sir or Madam:
I’m writing to ask you to take part in an important national survey sponsored by the U.S. Department of Health
and Human Services. The Health Information National Trends Survey has interviewed thousands of people in the last
few years. From it we’ve learned that:
About 4 out of 5 adults believe that there are so many recommendations about nutrition that it is hard to
know which ones to follow.
About one in four adults read the health section of a newspaper or magazine every week.
Almost half of all adults don’t know the age at which to begin screening for certain types of cancer.
With information like this, the survey can help the government and companies get valuable information on health
to you and your family.
Your household was chosen at random for this survey and cannot be replaced. We ask that each adult in this
household complete a questionnaire and return it to us in the postage-paid envelope at your earliest convenience.
What you have to say will help us find out how we can best provide the health information people need.
Westat, a research firm under contract with the U.S. Department of Health and Human Services, is administering
the survey. Your answers will be kept confidential to the extent provided by law. More information about the study is
provided on the back cover of this booklet.
Thank you in advance for your cooperation. If you have any questions about the study or you would like to
request more questionnaires, please call Westat toll-free at 1–888–636-6540.
Sincerely,
Bradford W. Hesse, Ph.D.
HINTS Project Officer
Chief, Health Communication and Informatics
Research Branch
National Institutes of Health
U.S. Dept of Health and Human Services
Si prefiere recibir la encuesta en Español, por favor llame 1-888-636-6536.
The Health Information National Trends Survey is authorized under 42 USC, Section 285a
In the box below, please enter the number of adults (age 18 or older) living in this
household:
Number of adults in household
Each adult in your household should fill out one questionnaire. Please be sure that
each adult has an opportunity to fill out a questionnaire. This is very important to the
success of the study.
If more questionnaires are needed, please call 1–888–636-6540.
Not all of the questions will apply to you – you will sometimes be asked to skip
questions based on your answers. In addition, certain sections of the questionnaire
may not apply to you.
To answer a question, simply check the box that best represents your answer.
Please choose only one answer per question, unless the question indicates Mark all
that apply. Your best estimate is fine.
The Privacy Act requires us to tell you that we are authorized to collect this information by Section 411.285a, 42 USC.
You do not have to provide the information requested. However, the information you provide will help the National
Cancer Institute’s ongoing efforts to promote good health and prevent disease. There are no penalties should you choose
not to participate in this study.
Public reporting burden for this collection of information is estimated to average 25 minutes per response, including the
time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not
required to respond to, a collection of information unless it displays a currently valid OMB control number. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 208927974, ATTN: PRA (0925-0538). Do not return the completed form to this address.
Someone else
Section A
Seeking Information about Health
A1.
Both myself and someone else
A5.
Have you ever looked for health information
about health or medical topics from any
source?
Based on the results of your most recent
search for health information about health or
medical topics, how much do you agree or
disagree with each of the following
statements?
Yes
No Go to Question A6
A2.
a. It took a lot of effort to get the
information you needed………
The most recent time you looked for health
information about health or medical topics,
where did you go first?
b. You felt frustrated during your
search for the information……
Mark only one.
Books
Magazines
Brochures,
pamphlets, etc.
Newspapers
Cancer
organization
Family
Friend/co-worker
Health care
provider
c. You were concerned about
the quality of the information...
d. The information you found
was hard to understand………
Telephone information
number
Complementary,
alternative, or
unconventional
practitioner
A6.
Overall, how confident are you that you could
get health-related advice or information if you
needed it?
Completely confident
Other Please
specify below:
Very confident
Internet
Somewhat confident
Library
A little confident
Not confident at all
A3.
Did you look or go anywhere else?
Mark all that apply.
No, nowhere else
Magazines
Books
Newspapers
Brochures,
pamphlets, etc.
Telephone information
number
Cancer
organization
Complementary,
alternative, or
unconventional
practitioner
Family
Friend/co-worker
Doctor or health
care provider
A7.
In general, how much would you trust
information about health or medical topics
from each of the following?
a. A doctor..................................
b. Family or friends.....................
c. Newspapers or magazines .....
Other Please
specify below:
d. Radio......................................
e. The Internet............................
Internet
f.
Library
g. Government health agencies..
Television ...............................
h. Charitable organizations.........
A4.
The most recent time you looked for health
information about health or medical topics,
who was it for?
i.
Myself
Question A6 appears in the next column.
1
Religious organizations and
leaders ...................................
B4.
Section B
Seeking Information about Cancer
The most recent time you looked for cancer
information, where did you go first?
Mark only one.
Books
B1.
Have you ever looked for information about
cancer from any source?
Brochures, pamphlets, etc.
Cancer organization
Yes
Family
No Go to Section C
Friend/co-worker
B2.
Doctor or health care provider
Think about the most recent time you looked
for cancer information. About how long ago
was that?
Internet
Library
Write a number in one box below
Days
Weeks
Months
Years
Magazines
Newspapers
Telephone information number
B3.
Complementary, alternative, or
unconventional practitioner
What type of information were you looking
for?
Other Please specify below:
Mark all that apply.
Specific cancer
Cancer organizations
Causes of cancer/Risk factors for cancer
Section C
Ways You Might Get Health Information
Coping with cancer/Dealing with cancer
Diagnosis of cancer
C1.
Information on cancer in general
Paying for medical care
Insurance
Prevention of cancer
Some newspapers or general magazines
publish a special section that focuses on
health. In the past 12 months, have you read
health sections of the newspaper or a general
magazine?
Prognosis/Recovery from cancer
Yes
Screening/Testing/Early detection
No
Symptoms of cancer
C2.
Treatment/Cures for cancer
Where to get medical care
Information on complementary, alternative, or
unconventional treatments
Other Please specify below:
Some local television and radio news
programs include special segments of their
newscasts that focus on health issues. In the
past 12 months, have you watched or
listened to health segments on the local
news?
Yes
No
Section C appears in the next column.
2
C3.
Some people notice information about health
on the Internet, even when they are not trying
to find out about a health concern they have
or someone in the family has. Have you read
such health information on the Internet in the
past 12 months?
C7.
Below are some ways people use the
Internet. Some people have done these
things, but other people have not. Please tell
us whether or not you have done each of
these things while using the internet in the
past 12 months.
Yes
Yes No
No
a. Bought medicine or vitamins online .... .
C4.
Do you ever go on-line to access the Internet
or World Wide Web, or to send and receive
e-mail?
b. Participated in an online support group
for people with a similar health or
medical issue...................................... .
Yes
c. Used e-mail or the Internet to
communicate with a doctor or a
doctor’s office ......................................
No Go to Section D
C5.
d. Used a website to help you with your
diet, weight, or physical activity............
Where do you go on-line to use the Internet?
Mark all that apply.
e. Looked for a healthcare provider .........
Home
Community Center
Work
Someone else’s house
f.
School
Some other place
g. Visited a “social networking” site, such
as myspace or Second Life .................
Public Library
Downloaded to a portable device, such
as an iPod, cell phone, or PDA............
h. Wrote in an online diary or blog ...........
C6.
When you use the internet at home, how do
you mainly access it?
i.
Do not use the internet at home
Telephone
modem
Wireless device
(such as a PDA)
Cable/satellite
modem
Another way Please
specify below:
DSL modem
Section D appears on the next page.
3
Kept track of personal health
information, such as care received,
test results, or upcoming medical
appointments.......................................
D4.
Section D
Your Use of Health Care Services
D1.
Not including psychiatrists and other mental
health professionals, is there a particular
doctor, nurse, or other health professional
that you see most often?
In the past 12 months, not counting times you
went to an emergency room, how many times
did you go to a doctor, nurse, or other health
professional to get care for yourself?
None Go to Question D9
Yes
1 time
4 times
2 times
5 to 9 times
3 times
10 or more times
No Go to Question D2
D1a. What kind of health professional do you see
most often?
D5.
A doctor
A nurse
The following questions are about your
communication with all doctors, nurses, or
other health professionals you saw during the
past 12 months. How often did they do each
of the following?
Other health professional Please specify
below:
a. Give you the chance to ask all
the health-related questions
you had....................................
D2.
Do you have any kind of health care
coverage, including health insurance, prepaid
plans such as HMOs, or government plans
such as Medicare?
b. Give the attention you needed
to your feelings and emotions..
c. Involve you in decisions about
your health care as much as
you wanted...............................
Yes
No
D3.
d. Make sure you understood the
things you needed to do to
take care of your health............
During the past 12 months, did you use any
complementary, alternative, or
unconventional therapies such as herbal
supplements, acupuncture, chiropractic,
homeopathy, meditation, yoga, or Tai Chi?
e. Help you deal with feelings of
uncertainty about your health
or health care...........................
Yes
D6.
No Go to Question D4
D3a. Did you discuss your use of unconventional
therapies with any of your doctors?
In the past 12 months, how often did you feel
you could rely on your doctors, nurses or
other health professionals to take care of your
health care needs?
Always
Yes
Usually
No
Sometimes
Never
Question D4 appears in the next column.
Question D9 appears on the next page.
4
D7.
Overall, how would you rate the quality of
health care you received in the last 12
months?
D11. Below are some reasons people give for not
wanting to see their health care provider or
doctor. Please tell us how much you agree or
disagree with each statement…
Excellent
Very good
Good
Fair
Poor
D8.
a. I avoid seeing my doctor
because I feel uncomfortable
when my body is being
examined................................
In the past 12 months, have you talked to a
doctor, nurse, or other health professional
about any kind of health information you have
gotten from the Internet?
b. I avoid seeing my doctor
because I fear I may have a
serious illness.........................
Yes
c. I avoid seeing my doctor
because it makes me think
about dying.............................
No Go to Question D9
D8a. In the past 12 months when you talked with a
health care professional, how interested were
they in hearing about the information you
found on-line?
D12.
Yes Please specify below:
Very interested
No
Somewhat interested
A little interested
Not at all interested
D9.
Are there any other reasons why you avoid
seeing your doctor?
Overall, how confident are you about your
ability to take good care of your health?
Completely confident
Very confident
Somewhat confident
A little confident
Not confident at all
D10. Some people avoid visiting their doctor even
when they suspect they should. Would you
say this is true for you, or not true for you?
True
Not true Go to Section E
Section E appears on the next page.
5
EX. Genetic tests that analyze your DNA, diet,
and lifestyle for potential health risks are
currently being marketed by companies
directly to consumers. Have you heard or
read about these genetic tests?
Section E
Views About Medical Information and Research
E1.
As far as you know, do your healthcare
providers maintain your medical information
in a portable, electronic format?
Yes
No
Yes
E4.
No
Have you ever had a genetic test?
Yes
E2.
No Go to Question E5
Please indicate how important each of the
following statements is to you.
E4a. How useful was the genetic test to you or
your physician?
Very useful
a. Health care providers should be
able to share your medical
information with each other
electronically .............................
Somewhat useful
Not at all useful
E5.
b. You should be able to get to your
own
medical
information
electronically .............................
Clinical trials are research studies that involve
people. They are designed to test the safety
and effectiveness of new treatments and to
compare new treatments with the standard
care that people currently get. Have you ever
participated in heard of a clinical trial?
Yes
E3. Please indicate how much you agree or
disagree with each of the following
statements.
No
E6.
a. In general, I think that the
information I give doctors is
safely guarded .......................
How important do you think it is for the
government to fund cancer research?
Very important
Important
Somewhat important
b. Scientists doing research
should be able to review
my medical information if
the information cannot be
linked to me personally...........
Not at all important
E7.
c. If I give permission for my
blood or tissue to be used
in a research study, other
approved studies may also
use it without further
permission from me................
For each of the following organizations,
please tell us if you had heard of it before
being contacted for this study.
Yes No
a. National Cancer Institute……………
b. CDC or the Centers for Disease
Control and Prevention ............……
c. The American Cancer Society ........
6
Section F
Nutrition and Physical Activity
The next two questions ask about fruits and vegetables. The following boxes provide some examples of how much counts
as 1 cup.
1 cup of fruit could be:
1 small apple
1 large banana
1 large orange
8 large strawberries
1 medium pear
2 large plums
32 seedless grapes
1 cup (8 oz.) of 100% juice
½ cup of dried fruit
1 small wedge of watermelon (1 inch thick)
F1.
1 cup of vegetables could be:
3 broccoli spears, 5 in. long
1 cup of cooked leafy greens
2 cups of lettuce or raw greens
12 baby carrots
1 medium potato
1 large sweet potato
1 large ear of corn
1 large raw tomato
2 large celery stalks
1 cup of cooked beans
About how many cups of fruit (including 100%
pure fruit juice) do you eat or drink each day?
Mark only one.
None
2 to 3 cups
½ cup or less
3 to 4 cups
½ to 1 cup
4 cups or more
1 to 2 cups
F2.
About how many cups of vegetables
(including 100% vegetable juice) do you eat
or drink each day? Mark only one.
None
2 to 3 cups
½ cup or less
3 to 4 cups
½ to 1 cup
4 cups or more
1 to 2 cups
F3.
How many servings of fruits and vegetables
do you think a person the average adult
should eat each day for good health?
Number of servings
F4.
During the past month, did you participate in
any physical activities or exercises such as
running, calisthenics yoga, golf, gardening, or
walking for exercise?
Yes
No Go to Question F5
7
F4a. In a typical week, how many days do you do
any physical activity or exercise of at least
moderate intensity, such as brisk walking,
bicycling at a regular pace, swimming at a
regular pace, and heavy gardening?
Moderate-intensity activities make you
breathe somewhat harder than normal.
F8.
About how tall are you without shoes?
Feet
F9.
None Go to Question F5
Inches
About how much do you weigh without
shoes?
1 day per week
Weight in pounds
2 days per week
3 days per week
4 days per week
FX. How much do you agree or disagree with the
following statement? There are so many
different messages about whether being
overweight is harmful to one's health it is hard
to know what weight one should maintain to
be healthy. Would you say you...
5 days per week
6 days per week
7 days per week
F4b. On the days that you do any physical activity
or exercise of at least moderate intensity,
how long are you typically doing these
activities?
Strongly agree
Somewhat agree
Somewhat disagree
Write a number in one box below
Minutes
F5.
Strongly disagree
Hours
F10. Right now, do you feel you are…
How many days a week of physical activity or
exercise of at least moderate intensity are
recommended for the average adult to stay
healthy?
Overweight
Slightly overweight
Slightly underweight
Number of days per week
Underweight
Just about the right weight for you
F6.
On those days, how long should the average
adult be physically active to stay healthy?
F11. Have you tried to lose any weight in the past
12 months?
Write a number in one box below
Minutes
F7.
Yes
Hours
No
As far as you know, which of the following
best describes the effect of physical activity
or exercise on the chances of getting some
types of cancer?
Physical activity increases chances of cancer
Physical activity decreases chances of cancer
Physical activity makes no difference
Question F5 appears in the next column.
8
F15. To what extent do you agree or disagree with
the following statement: I take the advice my
primary care provider or doctor gives about
diet and exercise.
F12. Have you tried a low carbohydrate, high
protein diet in the past 12 months?
Yes
Strongly agree
No
Somewhat agree
Neither agree nor disagree
F13. Do you think that a low carbohydrate, high
protein diet is a healthy way to lose weight?
Somewhat disagree
Strongly disagree
Yes
Have not received advice
No
Do not have a primary care provider/doctor
F14. Do you agree or disagree that sunlight helps
the body produce vitamin D naturally?
Agree
Disagree
9
F16. Please tell us how much you agree or disagree with each of the following statements.
If you do not have a primary care provider or doctor, go to Question F17.
Neither
Strongly Somewhat agree nor Somewhat Strongly
agree
agree
disagree disagree disagree
a. My primary care provider or doctor has effective
strategies and/or tools to help me maintain a
healthy weight or lose weight ....................................
b. My primary care provider or doctor has enough
time to talk with me about weight control...................
c. My primary care provider or doctor needs more
training in diet, weight, and physical activity
counseling.................................................................
d
I am more likely to adopt a healthier lifestyle if my
primary care provider or doctor recommends that
I do so .......................................................................
F17. Please indicate the extent to which you believe in each of the
following statements.
A lot
Some
Sometimes
Rarely
A little
Not at all
a. To what extent do you believe that genes can determine
your body weight and body composition (fat, muscle)
obesity is inherited?..................................................................
b. To what extent do you believe that genes can determine
how you respond to exercise and how many calories you
burn while exercising? ..............................................................
c. To what extent do you believe that obesity is not inherited,
but is caused by overeating and not exercising?.......................
Section G
Sun Exposure
G1.
When you are outside during the summer on a warm sunny day,
how often do you do each of the following?
Always
Often
Never
Do not go out
on sunny day
a. Wear sunscreen .....................................
b. Wear a shirt with sleeves that cover
your shoulders........................................
c. Wear a hat..............................................
d. Stay in the shade or under an umbrella ..
G2. How many times in the past 12 months have you...
a. Used a tanning bed or booth?...........................
b. Used sunless tanning creams or sprays, also
known as self-tanning or fake tanning? This
includes creams or lotions that you apply by
10
0 times
1 to 2
times
3 to 10
times
11 to 24
times
25 times
or more
yourself or mist tans from a tanning salon or
other business…………………………………….
11
H5.
Section H
Tobacco Use
H1.
In the past 12 months, have you tried to quit
smoking completely?
I have not smoked
in the past 12 months Go to Question H7
Have you smoked at least 100 cigarettes in
your entire life?
Yes
No
Yes
No Go to Question H8
H2.
H6.
Are you seriously considering quitting
smoking within the next 6 months?
How often do you now smoke cigarettes?
Every day
Some days Go to Question H3
Yes Go to Question H8
No Go to Question H8
I have already quit smoking
Not at all Go to Question H4
H7.
H2a. On the average, how many cigarettes do
you now smoke a day?
About how long has it been since you
completely quit smoking cigarettes?
Write a number in one box below
Write in number and go to Question H5
Number of cigarettes per day
H3.
Days
Weeks
Months
Years
On how many of the past 30 days, did you
smoke a cigarette?
H8.
Number of days
Do you believe that some cigarettes are less
harmful than others?
Yes
No
H3a. On the average, when you smoked during the
past 30 days, about how many cigarettes did
you smoke a day?
H9.
Number of cigarettes per day
If a new cigarette were advertised as less
harmful than current cigarettes, how
interested would you be in trying it?
Very interested
Somewhat interested
H4.
Have you ever smoked cigarettes every day
for at least 6 months?
Not interested Go to Question H10
Yes
H9a. How likely would you be to switch to a safer
or less harmful cigarette product instead of
trying to quit smoking?
No Go to Question H5
H4a. When you last smoked every day, how many
cigarettes did you usually smoke each day?
I have not smoked in the past 12 months
Very likely
Somewhat likely
Number of cigarettes per day
Not at all likely
Question H5 appears in the next column.
Question H8 appears in the next column.
Question H10 appears on the next page.
12
H14a. Have you ever called a telephone quitline?
H10. Have you ever tried a cigarette that had been
advertised as less harmful? This includes
products like Eclipse, Advance, and Quest.
Yes
No
Yes
No
H14b. In the past 12 months, did any doctor,
dentist, nurse, or other health professional
suggest that you call or use a telephone
helpline or quit line to help you quit
smoking?
H11. Do you believe that some smokeless tobacco
products, such as chewing tobacco and snuff,
are less harmful than cigarettes?
I have not smoked in the past 12 months
Yes
Yes
No
No
H12. If a new smokeless tobacco product that
didn't require spitting were advertised as less
harmful than current cigarettes, how
interested would you be in trying it?
H14c. How likely would you be to call a smoking
cessation telephone quitline in the future, for any
reason?
Very likely
Very interested
Somewhat likely
Somewhat interested
Somewhat unlikely
Not interested Go to Question H13
Very unlikely
H12a. How likely would you be to switch to a new
smokeless tobacco product instead of trying
to quit smoking?
H15. Before being contacted for this survey, had
you ever heard of 1-800-QUIT-NOW?
I have not smoked in the past 12 months
Yes
Very likely
No
Somewhat likely
Not at all likely
H16. Have you heard of any tests to find lung
cancer before the cancer creates noticeable
problems?
H13. Have you ever tried a smokeless tobacco
product that had been advertised as less
harmful? This includes products like Ariva,
Revel, and Camel Snus.
Yes
No Go to Section I
Yes
H16a. What tests have you heard of?
No
Mark all that apply.
H14. There are a number of resources that people
use to help them stop smoking. Before being
contacted for this survey (and regardless of
whether or not you smoke), had you ever
heard of telephone quitlines such as a tollfree number to call for help in quitting
smoking?
Chest x-ray
CAT Scan or Spiral CT
Lung biopsy
Blood test
Cannot recall name
Other Please specify below:
Yes
No Go to Question H15
Question H15 appears in the next column.
Section I appears on the next page.
13
I5.
Section I
HPV and Cervical Cancer
I1.
When do you expect to have your next Pap
test? Mark only one.
A year or less from now
More than 1 but not more than 3 years
from now
Are you male or female?
Female
More than 3 but not more than 5 years
from now
Male Go to Question I6
Over 5 years from now
I2.
Am not planning to have another
Sometimes, when a woman has a routine
pelvic exam, she also has a Pap test to test
for cancer of the cervix. Have you ever had a
Pap test?
If I have symptoms
When doctor/health care provider
recommends
Yes
I am not planning to have another because
I got or am planning to get the HPV vaccine
No Go to Question I6
I3.
I am not planning to have another because
I got or am planning to get the HPV test
instead
When did you have your most recent Pap test
to check for cervical cancer?
1 year ago or less
More than 1 but not more than 3 years ago
I6.
More than 3 but not more than 5 years ago
More than 5 years ago
Have you ever been told by a health care
provider that you had a human papillomavirus
or HPV infection?
Yes
I4.
What was the main reason that you had this
Pap test? Mark only one.
No
I7.
Routine annual Pap test or part of routine
physical exam
Have you heard anything about a vaccine or
shot to prevent cervical cancer?
Last Pap test was not normal
Yes
A specific problem
No
Never had one and thought you should
Pregnancy/Followup to birth
I8.
Other Please specify below:
Have you ever heard of HPV? HPV stands for
Human Papillomavirus. It is not HIV, HSV, or
herpes.
Yes
No Go to Question I12
Question I6 appears in the next column.
Question I12 appears on the next page.
14
I8a.
Where have you
Mark all that apply.
heard
about
I12. A vaccine or shot that protects against HPV,
a virus that can cause cervical cancer, was
recently recommended for girls ages 9-12. If
you had a daughter that age, would you have
her get it?
HPV?
Doctor, nurse or other health care
professional
Family or friends
Newspaper or magazine
Yes Go to Question I13
Television
No
Internet
Not sure/It depends
Radio
Don't remember
I12a. What is the main reason you would not have
her get it? Mark only one.
Other Please specify below:
She doesn't need the vaccine or shot
My child is not sexually active
It is too expensive
Vaccinations (shots to prevent sickness) in
general are not necessary
Next are some questions on your opinion about
HPV.
I don't know where to get it
My child's doctor has not recommended it
I9.
Do you think HPV can cause cervical cancer?
I am worried about the safety of the vaccine
Yes
My partner is against it
No
I don't believe it will work
My mother or others in my family are against
it
I10. Do you think you can get HPV through sexual
contact?
I am worried that the vaccine or shot might
promote sexual activity
Yes
I worry what others would think if they found
out she got it
No
Other Please specify below:
I11. Do you think HPV can go away on its own,
without any treatment?
Yes
No
I13. Have you ever been treated for genital warts?
Yes
No
15
Section J
Colon Cancer
J1.
J4. The last time you were told you should be
tested for colon cancer, which tests did the
health professional describe?
Are you 45 years old or older?
Yes
Yes No
No Go to Section K
a. Stool or fecal blood test..............
b. Colonoscopy...............................
c. Sigmoidoscopy...........................
The next few questions are about getting tested for
colon cancer.
J2. Think about the last time a doctor, nurse or
other health professional told you that you
should get a test to check for colon cancer.
When did that discussion take place?
J5.
Yes
No Go to Question J6
A year ago or less
More than 1 but not more than 2 years ago
Did the health professional describe any
other tests?
J5a. What test did the health professional
describe? Please specify below:
More than 2 but not more than 5 years ago
Over 5 years ago Go to Question J9
I do not remember Go to Question J9
No health professional has told me I should
get this test Go to Question J9
J6.
J3. Who talked to you about getting a test to
check for colon cancer? Mark all that
The last time you were told you should be
tested for colon cancer, did the health
professional recommend to you any particular
test?
Yes
apply.
No Go to Question J7
Doctor
Nurse
J6a. Which test to check for colon cancer did the
health professional recommend to you?
Mark all that apply.
Other health professional
Stool blood test/fecal occult blood test
Sigmoidoscopy
A stool or fecal occult blood test is done at
home to check for colon cancer. You send
your stool sample to the doctor’s office or lab
for testing. This does not include drugstore or
pharmacy test kits.
Colonoscopy
Other Please specify below:
A colonoscopy and a sigmoidoscopy are
both tests that examine the bowel by inserting
a tube in the rectum.
J7.
- During a colonoscopy, you may feel sleepy
and need someone to drive you home.
Who decided whether you should have a test
to check for colon cancer?
You mainly decided
You and the health professional decided
together
- During a sigmoidoscopy, you are awake
and can drive yourself home after the test
The health professional mainly decided
Question J9 appears on the next page.
Section K appears on page 16.
16
J8.
Thinking about the last time a health
professional talked to you about being
checked for colon cancer, did he or she
encourage you to ask questions or express
any concerns you had about colon cancer
testing?
J10b. What was the main reason you had your
most recent colonoscopy? Mark only one.
Part of a routine exam
Because of a problem
Some other reason
Yes, definitely
Yes, somewhat
J11. Have you ever had a sigmoidoscopy?
No, not at all
Yes
I did not have any questions or concerns
about colon cancer testing
J9.
No Go to Question J12
J11a. When did you have your most recent
sigmoidoscopy?
Have you ever done a stool blood test, also
known as a fecal occult blood test?
A year ago or less
Yes
More than 1 but not more than 5 years ago
No Go to Question J10
More than 5 but not more than 10 years ago
Over 10 years ago
J9a. When did you do your most recent stool
blood test/fecal occult blood test?
J11b. What was the main reason you had your
most recent sigmoidoscopy?
A year ago or less
More than 1 but not more than 2 years ago
Part of a routine exam
More than 2 but not more than 5 years ago
Because of a problem
Over 5 years ago
Some other reason
J9b. What was the main reason you did your most
recent stool blood test/fecal occult blood test?
J12. We’ve asked about three tests to find colon
cancer: the stool blood test, colonoscopy, and
sigmoidoscopy. Do you believe these tests
are about equally effective in finding colon
cancer, or are some more effective than
others?
Mark only one.
Part of a routine exam
Because of a problem
Some other reason
Equally effective Go to Section K
Some are more effective than others
J10. Have you ever had a colonoscopy?
Yes
J12a. Which test (or tests) do you believe is more
effective in finding colon cancer?
Mark one or two.
No Go to Question J11
J10a. When did you have your most recent
colonoscopy?
Stool blood test/fecal occult blood test
Colonoscopy
A year ago or less
Sigmoidoscopy
More than 1 but not more than 5 years ago
More than 5 but not more than 10 years ago
Over 10 years ago
Question J11 appears in the next column.
Section K appears on the next page.
17
Section K
Communicating Health
Information with Numbers
K2.
Section L
Beliefs About Cancer
In general, how easy or hard do you find it to
understand medical statistics?
This section contains several questions about cancer. For
each, try to think about cancer in general when
answering.
Very easy
Easy
L2.
Hard
Very hard
K3.
How likely do you think it is that you will
develop cancer in the future?
Very low
Somewhat low
How much do you agree or disagree with the
following statement?
In general, I depend on numbers and
statistics to help me make decisions about
my health.
Moderate
Somewhat high
Very high
Strongly agree
Somewhat agree
L3.
Somewhat disagree
Strongly disagree
How often do you worry about getting
cancer?
Rarely or never
Sometimes
K4.
Which of the following numbers represents
the biggest risk of getting a disease?
Often
All the time
1 in 100
1 in 1,000
L1.
1 in 10
K1.
How much do you agree or disagree with this
statement?
When I think of cancer, I automatically think
of death.
People can talk about the chance of something
happening using either words, like "It rarely
happens" or numbers, like "There's a five percent
chance."
When people tell you the chance of something
happening do you prefer they use words or
numbers?
Strongly agree
Somewhat agree
Somewhat disagree
Strongly disagree
Generally prefer words
Generally prefer numbers
No preference
18
L4.
Section M
Your Cancer History
How much do you agree or disagree with
each of the following statements?
M1. Have you ever been diagnosed as having
cancer?
Yes
a. Cancer is most often caused
by a person's behavior or
lifestyle…………………………
No Go to Question M4
b. Getting checked regularly for
cancer helps find cancer when
it's easy to treat……………….
M1a. What type of cancer did you have?
Mark all that apply.
Bladder cancer
c. People can tell they might
have cancer before being
diagnosed……………………...
Bone cancer
Breast cancer
d. Cancer is an illness that when
detected early can typically be
cured……………………………
Cervical cancer (cancer of the cervix)
Colon cancer
e. It seems like everything
causes cancer…………………
Endometrial cancer (cancer of the uterus)
f.
Hodgkin's lymphoma
Head and neck cancer
There's not much you can do
to lower your chances of
getting cancer………..……….
Leukemia/blood cancer
Liver cancer
g. There are so many different
recommendations
about
preventing cancer, it's hard to
know which ones to follow…...
Lung cancer
Melanoma
Non-Hodgkin's lymphoma
Other skin cancer
L5.
Oral cancer
Overall, how many people who develop
cancer do you think survive at least 5 years?
Ovarian cancer
Less than 25 percent
Pancreatic cancer
About 25 percent
Pharyngeal (throat) cancer
About 50 percent
Prostate cancer
About 75 percent
Rectal cancer
Nearly all
Renal (kidney) cancer
Stomach cancer
Other Please specify below:
L6.
When you hear the word cancer, what type of
cancer comes to mind first?
Please specify below:
Question M4 appears on the next page.
19
N2.
M2. At what age were you first told that you had
cancer?
Please tell us whether or not a doctor has
ever told you that you had each of the
following health conditions.
Age
Yes No
a. Diabetes or high blood sugar......
M3. Did you ever receive any treatment for your
cancer?
b. High
blood
pressure
or
hypertension...............................
Yes
c. A heart condition such as a heart
attack, angina, or congestive
heart failure ................................
No Go to Question M4
M3a. How long ago did you finish your most recent
treatment?
d. Chronic lung disease, asthma,
emphysema,
or
chronic
bronchitis....................................
I am still in treatment Go to Question M4
e. Arthritis or rheumatism ...............
Write a number in one box below
Months
f.
Depression or anxiety disorder ...
Years
N3.
M4. Have any of your family members ever had
cancer?
Next are some questions about feelings you may
have experienced over the past 30 days.
How often did you feel each of the following
during the past 30 days?
Yes
No
Have no family
a. So
sad
that
nothing
could
cheer you up........
b. Nervous...............
c. Restless
or
fidgety..................
Section N
Your Health Status
N1.
d. Hopeless .............
e. That everything
was an effort........
In general, would you say your health is…
f.
Excellent
Worthless ............
Very good
Good
N4.
Fair
Poor
In the past 12 months, has there ever been a
time when you drank 5 or more alcoholic
beverages almost every day? By drink, we
mean a 12 ounce beer, a 4 ounce glass of
wine, or an ounce of liquor.
Yes
No
20
Section O
About You and Your Household
O6. Are you Hispanic or Latino?
Yes
O1. What is your age?
No
years old
O7. Which one or more of the following would you
say is your race? Mark all that apply.
White
O2. Are you male or female?
Black/African American
Male
American Indian/Alaska Native
Female
Asian
Native Hawaiian/other Pacific Islander
O3. What is your current occupational status?
Mark only one.
Employed
Student
Unemployed
Retired
Homemaker
Disabled
O8. Were you born in the United States?
Yes Go to Question O9
No
Other Please specify below:
O8a. In what year did you come to live in the
United States?
O4. What is your marital status?
Year
Married
Living as married
O9. How many children under the age of 18 live in
your household?
Divorced
Widowed
Number of children under 18
Separated
Single, never been married
O10. Are any of the children in your household
female?
O5. What is the highest grade or level of
schooling you completed?
Yes
Less than 8 years
No
8 through 11 years
No children in household under 18
12 years or completed high school
Post-high school training other than college
(vocational or technical)
Some college
College graduate
Postgraduate
21
O11. Thinking about members of your family living
in this household, what is your combined
annual income, meaning the total pre-tax
income from all sources earned in the past
year?
O17. Does anyone in your family have a working
cell phone?
Yes
No
$0 to $9,999
$10,000 to $14,999
O18. At which of the following types of addresses
does your household currently receive
residential mail? Mark all that apply.
$15,000 to $19,999
$20,000 to $34,999
$35,000 to $49,999
$50,000 to $74,999
A street address with a house or building
number
$75,000 to $99,999
An address with a rural route number
$100,000 to $199,999
A U.S. post office box (P.O. Box)
$200,000 or more
A commercial mail box establishment (such
as Mailboxes are Us, Mailboxes, Etc.)
O12. Do you currently rent or own your home?
Own
Rent
Thank you!
Occupy without paying monetary rent
O13. Did you complete this survey all in one sitting,
or did you do it in more than one sitting?
Please remember that we would like all persons age
18 years or older in this household to complete a
questionnaire. If more questionnaires are needed,
please call
1–888–636-6540.
I completed the survey all in one sitting.
I completed the survey in more than one
sitting.
Please return this questionnaire in the postage-paid
envelope provided. If you have lost the envelope,
mail the completed questionnaire to:
O14. Did anyone help you complete this survey?
Yes
No
HINTS Study, TC1021F
Westat
1650 Research Blvd.
Rockville, MD 20850
O15. How long did it take you to complete the
survey?
Write a number in one box below
Minutes
If you have any questions about cancer or want
some information about cancer, you can call 1-8004-CANCER or go to the National Cancer Institute’s
web site at: www.cancer.gov.
Hours
O16. Is there at least one telephone inside your
home that is currently working and is not a
cell phone?
Yes
No
22
Some Frequently Asked Questions
about the
Health Information National Trends Survey
Q: What is the study about? What kind of questions will you be asking?
A: The study concerns health and how people receive health information. For example, we will ask
how you usually get information about how to stay healthy, the sources of information you most
trust, and how you might like to get such information in the future. We will also ask about your
beliefs on what contributes to good health, how best to prevent cancer, your participation in
various health-related activities, and related topics.
Q: How will the study results be used? What will be done with my information?
A: Findings will help the U.S. Department of Health and Human Services promote good health and
prevent disease, by determining ways of better communicating accurate health information to
people.
Q: How did you get my address?
A: Your address was randomly selected from among all of the known home addresses in the nation.
It was selected using scientific sampling methods.
Q: Why should I take part in this study? Do I have to do this?
A: Your participation is voluntary, and you may refuse to answer any questions or withdraw from
the study at any time. Your household was selected randomly using scientific sampling methods,
in order to reach a sample that reflects the entire population of the United States. You represent
thousands of other households like yours, and you cannot be replaced. Your answers and opinions
are very important to the success of this study, as you represent others who share your knowledge
and beliefs.
Q: Will my answers to the survey be kept confidential?
A: Yes. Your answers will not be revealed to anyone but the researchers in a way that identifies you
or your household, to the extent provided by law.
Q: How long will it take to answer the questions?
A: About 20 to 30 minutes.
Q: Who is sponsoring the study? Is this study approved by the Federal Government?
A: The study is sponsored by the U.S. Department of Health and Human Services. The study has
been approved by the Office of Management and Budget (OMB), the office that reviews all
federally-sponsored surveys. The OMB approval number assigned to this study is 0925-0538.
Q: Who is Westat?
A: Westat is a research company located in Rockville, Maryland. Westat is conducting this survey
under contract to the U.S. Department of Health and Human Services.
23
| File Type | application/pdf |
| File Title | ATTACHMENT A: |
| Author | Terri Davis |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |