Questionnaires, Scripts, and Letters

Attachment 6
Letters, Instructions to Respondents, and Telephone Scripts

Physician Survey of Practices on Diet, Physical Activity, and
Weight Control
Study Sponsor
This survey is being sponsored by The National Cancer Institute at the National Institutes
of Health (NIH).
Co-funding is provided by The National Institute for Child Health and Human
Development, and The Office of Behavioral and Social Sciences Research in the Office
of the Director at NIH.
Purpose
The purpose of this study is to obtain current, national data on physician’s knowledge,
attitudes, and activities related to diet, physical activity, and weight control. In addition,
the study will seek information on what administrative structures support or hinder
physician’s practices in these areas. Study data will be used to improve public health
experts’ understanding of whether and how related practices are implemented in primary
care settings, with the ultimate goal being to improve the quality of the nations’ health.
Background Information
There is an increasing body of literature supporting the relationship between lifestyle
factors and disease. Diet, physical activity and weight control influence the risk and
prognosis for many chronic diseases. Obesity, physical inactivity, and poor diet are
major problems affecting quality of life for both adults and children. Though physicians
play a key role in providing information to patients about the benefits of a healthy
lifestyle, little is known about physician practices and attitudes related to diet, physical
activity or weight control, or the administrative structures related to these practices.
Participation
A nationally representative sample of 2,000 physicians in the specialties of Internal
Medicine, Pediatrics, Family Practice, and Obstetrics/Gynecology were randomly
selected from a nation-wide database of physicians to receive a survey. Among these
practices, an additional sub sample of 1,000 practice administrators was selected to
receive a brief administrative survey.
Your participation is voluntary, and there are no penalties to you for not responding.
However, not responding could affect the accuracy of results, and your point of view may
not be represented in the findings of the study.
Questionnaire Description
The Physician Survey of Practices on Diet, Physical Activity, and Weight Control collects
information using two different questionnaires. The Physician Questionnaire asks
questions about how knowledge, attitudes, and practices related to diet, physical activity,
and weight control have been integrated into Physician practices. The Administrator
Questionnaire collects information about administrative protocols and systems that could
influence physician behavior.

Physician questions cover such areas as:
o Clinical practice behaviors
o Assessment, referral, counseling, general guidance about diet, physical
activity and weight
o Knowledge of the science and available guidelines
o Attitudes, self-efficacy and importance of diet, physical activity and weight
control in disease prevention
o Personal habits of physicians related to diet, exercise, and weight control
Administrator questions include:
o Practice characteristics such as location, size affiliation (number and type of
health care professionals)
o Patient characteristics
o Practice guidelines, reminders, protocols
o Availability and adequacy of reimbursement and billing practices
o Availability of community resources for referrals
Confidentiality of Responses
All survey responses will be kept confidential, with each survey assigned an
identification number. The data file with names and numbers will be stored separately
from all completed surveys and the data file containing survey responses. Names will
never be directly associated with responses. Data from individual responses will be
aggregated and reported in statistical form. Comments from individual surveys may be
thematically coded and reported in the aggregate. Some comments may be quoted
verbatim but without attribution to the individual making the comment.
Uses of the Data
Results of the survey will be used in:
o Publications in peer-reviewed journals;
o Presentations at national meetings; and
o Government reports on health care policy.
Data will also be used to provide survey analysis experience for post-doctoral fellows,
and instruments will be made available for use by other investigators researching similar
issues.
Further Questions
If you have questions about the study, please call 1-800-937-8281 x2786 toll-free to
speak with Dr. Caroline McLeod, the Project Director. Or, please call the Government
Project Officer at the National Cancer Institute, Dr. Ashley Wilder Smith at
(301) 451-1843.

July 2, 2007
Name
Address
Address
City State Zip
Dear Dr.

:

The National Cancer Institute (NCI) at the National Institutes of Health (NIH), along with the National Institute of
Child Health and Human Development and the Office of Behavioral and Social Sciences Review, request your
participation in a physician survey of their knowledge, attitudes, and practices regarding diet, physical activity, and
weight management. We are sending this survey to a group of 2,000 randomly selected physicians, including you.
There is an increasing body of literature supporting the relationship between poor diet, low levels of physical
activity, being overweight, and the risk of chronic disease. The goal of this survey is to understand physicians’
practices regarding the use of risk assessment, counseling and referral services for diet, physical activity and weight
control. Data from the survey will be used to understand existing physician practice, understand barriers to
counseling and referral, and to inform methods for improving the utilization of these services for adults and
children. We need your views on these practices.
We will combine your responses with those of other surveyed physicians, and use these data to publish publiclyavailable reports and journal articles with the goal of informing health care policy and improving health care.
Completing the enclosed questionnaire should take no longer than 20 minutes, and space is left at the end for
comments. The information you provide is confidential. Your participation is voluntary; there are no penalties for
not responding to the information collection as a whole or to any particular questions. Your answers will be stored
separately from your identity, and only aggregated findings will be reported. A $30 check is enclosed as a token of
our appreciation for your participation.
Please complete this one-time survey and return it in the enclosed envelope. If you would prefer to complete your
survey by telephone with a researcher, please call 800-937-8281 ext 1234, weekdays between 9 a.m. and 5 p.m.
EDT, or e-mail [email protected]. If you have questions about the study, please call Dr. Caroline
McLeod, Westat, (800-937-8281 ext. 2786 or [email protected]) or Dr. Ashley Wilder-Smith at NCI
(301) 451-1843 or [email protected]).
Your participation is both critical and much appreciated. Thank you in advance for your valuable contribution to
this important study.
Sincerely,

Rachel Ballard-Barbash, M.D.
Associate Director
Division of Cancer Control and Population Sciences
National Cancer Institute

July 2, 2007
Name
Address
Address
City State Zip
Dear Dr.

:

About two weeks ago we sent you, via FedEx, a survey focused on physicians’ practices regarding the use of risk
assessment, counseling and referral services for diet, physical activity and weight control. A check for $30 was
enclosed in the survey package in appreciation for your participation.
If you have already completed and returned the questionnaire, thank you. If you have not yet done so, I hope you
will take a few minutes to complete and return the enclosed survey at your earliest convenience. If you would prefer
to provide your responses by telephone rather than fill the form out by hand, please call Miriam Aiken, toll free at 1800-937-8281 ext. 2828. You can also e-mail her at [email protected].
As an office-based practitioner, you play a critical role in counseling patients about the adoption of healthy
behaviors. We need your views in order to understand what care is being provided on the front lines of patient care,
and what barriers exist to providing services related to diet, physical activity, and weight control. Currently, there
are no nationally representative data available in this subject area.
We at the National Cancer Institute greatly appreciate your continued commitment to the field of preventing disease
and promoting health. If you have any questions or concerns about your participation in this survey, please call Dr.
Caroline McLeod, Project Director, at 1-800-937-8281 ext. 2786. Again, thank you for your valuable contribution to
this important effort. We look forward to your response.

Sincerely,

Rachel Ballard-Barbash, M.D.
Associate Director
Division of Cancer Control and Population Sciences
National Cancer Institute

July 2, 2007
Name
Address
Address
City State Zip
Dear Mr./Ms./Dr.

:

The National Cancer Institute (NCI) at the National Institutes of Health (NIH), along with the National Institute of
Child Health and Human Development, the National Institute of Diabetes and Digestive and Kidney Diseases, and
the Office of Behavioral and Social Sciences Review, request your participation in a survey of practice
administrators and physicians. Research indicates that there are links between poor diet, low levels of physical
activity, being overweight, and the risk of chronic disease. Our Administrator Survey collects information about
practice and office systems that support or hinder clinicians’ activities related to diet, physical activity and weight
control. We are sending this survey to 1,000 administrators working with 2,000 randomly selected physicians.
A physician in your office, _________, MD has recently completed the Physician portion of our survey. We
understand that you are the best person in your office to answer the questions about the practice itself. We are
hoping you will be willing to help us out with this important Administrator Survey.
We will combine your responses with those of other surveyed administrators, and use these data to publish publiclyavailable reports and journal articles with the goal of informing health care policy and improving health care.
Completing the enclosed questionnaire should take no longer than 20 minutes, and space is left at the end for
comments. The information you provide is confidential. Your participation is voluntary; there are no penalties for
not responding. Your answers will be stored separately from your identity, and only aggregated findings will be
reported. A $30 check is enclosed as a token of our appreciation for your participation.
Please complete this one-time survey and return it in the enclosed envelope. If you would prefer to complete your
survey by telephone with a researcher, please call 800-937-8281 ext 2828, weekdays between 9 a.m. and 5 p.m.
EDT, or e-mail [email protected]. If you have questions about the study, please call Dr. Caroline
McLeod, Westat, (800-937-8281 ext. 2786 or [email protected]) or Dr. Ashley Wilder-Smith at NCI
(301) 451-1843 or [email protected]).
Your participation is both critical and much appreciated. Thank you in advance for your valuable contribution to
this important study.
Sincerely,

Rachel Ballard-Barbash, M.D.
Associate Director
Division of Cancer Control and Population Sciences
National Cancer Institute

July 2, 2007
Name
Address
Address
City State Zip
Dear Mr./Ms./Dr.

:

About two weeks ago we sent you, via FedEx, a survey focused on physicians’ practices regarding the use of risk
assessment, counseling and referral services for diet, physical activity and weight control. A check for $30 was
enclosed in the survey package in appreciation for your participation.
A physician in your office, _________, MD has recently completed the Physician portion of our survey. We
understand that you are the best person in your office to answer the questions about the practice itself. Your office
plays a critical role in counseling patients about the adoption of healthy behaviors. We need your views in order to
understand what care is being provided on the front lines of patient care, and what barriers exist to providing
services related to diet, physical activity, and weight control. Currently, there are no nationally representative data
available in this subject area.
If you have already completed and returned the questionnaire, thank you. If you have not yet done so, I hope you
will take a few minutes to complete and return the enclosed survey at your earliest convenience. If you would prefer
to provide your responses by telephone rather than fill the form out by hand, please call Miriam Aiken, toll free at 1800-937-8281 ext. 2828. You can also e-mail her at [email protected].
We at the National Cancer Institute greatly appreciate your continued commitment to the field of preventing disease
and promoting health. If you have any questions or concerns about your participation in this survey, please call Dr.
Caroline McLeod, Project Director, at 1-800-937-8281 ext. 2786. Again, thank you for your valuable contribution to
this important effort. We look forward to your response.
Your participation is both critical and much appreciated. Thank you in advance for your valuable contribution to
this important study.
Sincerely,

Rachel Ballard-Barbash, M.D.
Associate Director
Division of Cancer Control and Population Sciences
National Cancer Institute

January 2008

Dear Colleage:
The National Cancer Institute of the National Institutes of Health (NCI) is
conducting a national research study of physicians’ recommendations and practices
related to diet, physical activity, and weight control. Poor diet, low levels of
physical activity, and obesity are becoming increasingly recognized as national
public health problems. As physicians, we play a critical role in the prevention of
disease through advice and counseling regarding healthy behaviors. It is important
that NCI understand your perceptions of these disease prevention activities, as well
as whether and how these activities are being performed in the U.S.
This is an important study and I encourage you to participate in the survey. This
national survey will collect information about your beliefs, practice style, practice
characteristics, training/experience, and other factors that may influence your
practices. Upon the completion of the study, the data gathered will be analyzed
and findings disseminated through public health conferences and peer-reviewed
medical journals. By completing this survey, you will assist the NCI in gaining a
better understanding of disease prevention services in the United States, including
identifying issues that either enhance or impede their delivery.
I encourage you to complete the survey. Your participation in this initiative is vital
to assisting the NCI with its goals of preventing disease and promoting health.
Thank you in advance.

Sincerely,

Rick D. Kellerman, M.D., FAAFP
President

Energy Balance Study
RESPONDENT INFORMATION SHEET (RIS)
[OFFICE or HOME] ADDRESS
ID:

12345

NAME:

(BAR CODE)

John Doe

VERIFY
[

]

[

]

UPDATE

Currently In Practice
|__| Deceased

PHYSICIAN PRACTICE:

|__| No longer in practice/retired
|__|Family Practitioner
|__| Sees patients under 18 years old
|__| Internist
|__| Sees most patients in hospital vs. office/hospitalist
|__| OB-GYN

SPECIALTY: OB-GYN

|__| sub-specialty such as, high risk pregnancies or
oncology

|__| Pediatrician
[

]

Medical Clinic
6917 Valley Ridge
Suite 100

[

]

CITY:

Monroe

[

]

STATE:

NC

[

]

ZIP:

27615

[

]

PHONE:

211-899-9916

[

]

ADDRESS:

Other (specify):_______________________

ADMINSTRATOR NAME: ___________________________________________

COMMENTS:________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
TRACING COMPLETED:

Internet Tracing Completed

DA Completed

Energy Balance
Cancer Screening Recommendations and Practices
Telephone Screener for Verification of Address and Eligibility
Hello, this is (INTERVIEWER'S NAME) and I am calling on behalf of the National Institutes of Health
regarding a study on cancer screening.
•

Is this the office for Dr. (FIRST, MIDDLE INITIAL, LAST NAME)? (CONFIRM/UPDATE
THE INFORMATION ON THE RIS)
If YES, CONTINUE TO CONFIRM/ UPDATE THE REMAINING INFORMATION ON THE RIS BY
ASKING:

•

•

Is Dr. (LAST NAME) a (FILL IN SPECIALTY FROM RIS)? (RECORD INFORMATION ON
THE RIS).
(IF NOT A FAMILY PRACTITIONER, INTERNIST, OB-GYN, OR GENERAL
PRACTITIONER)
What type of specialist is s/he? (RECORD INFORMATION ON
THE RIS)
Is (his/her) address (READ ADDRESS FROM THE RIS AND CONFIRM/UPDATE AS
APPROPRIATE)?
If YES
Thank you for your time. (END CALL)
If NO:
(AND THE PHYSICIAN IS DECEASED, RECORD ON THE RIS) Thank you for your
time. (END CALL)
(IF THE PHYSICIAN IS RETIRED OR NO LONGER IN PRACTICE, RECORD IN THE
RIS) Thank you for your time. (END CALL)
(OTHERWISE ASK)
• Do you know how I might reach the doctor?
If YES, RECORD THE INFORMATION IN THE COMMENTS SECTION OF THE RIS. Thank
you for your time. (END CALL)
If NO
• Could you tell me who at the office might know how to reach Dr. (LAST NAME)), and
could you transfer me to that person?
IF YES:
(RECORD THE NAME ON THE RIS. THEN SPEAK TO THE NEW CONTACT,
MAKING SURE TO DOCUMENT ANY ADDITIONAL INFORMATION IN THE
COMMENTS SECTION). Thank you for your time. (END CALL)
IF NO:
• Do you know what hospital Dr. (LAST NAME) was affiliated with while
working at your location? (RECORD ANY ADDITIONAL INFORMATION IN THE
COMMENTS SECTION).
Thank you for your time. (END CALL)

TASK 4/Screening Calls/Screening script 5/7.20.06