Attach 4a - Patient Pre-Intervention Survey

Attachment 4a_Changes_Patient_ Pre-Intervention_ Survey.doc

Evaluation of an Intervention to Increase Colorectal Cancer Screening in Primary Care Clinics

Attach 4a - Patient Pre-Intervention Survey

OMB: 0920-0769

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Form Approved

OMB Control No: 0920-0769

Expiration Date: 03/31/2011






Clinical Care and Health Survey:

Patient Opinions


Patient Opinion Survey











Funded by

The Centers for Disease Control and Prevention

Atlanta, GA



Public reporting burden of this collection of information varies from 15 to 30 minutes with an estimated average of 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining 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 CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0769)









We are interested in your opinions and experiences when talking with your doctor or health care provider 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 doctor about these issues. Your opinions are important to us!


Filling in this survey will help us design programs to help your doctor 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 had when talking with your doctor about colon cancer.


For this study, selected patients 50 years old and older who are active members of the Henry Ford Health System are being sent this survey. You are being paid $10 to compensate you for your time and effort.


  • Your answers are strictly private


  • Please do not put your name on the 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!






Instructions and Question Examples


This survey has questions that come in different forms several ways it asks questions. When any question asks about “your doctor,” 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:


A1.

What is your age?


Age





A2.

Are you male or female?


  • Male

  • Female


You will need to write in your age and check () the box for male or female.





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

For example, some questions look like this:


A3.

How satisfied are you with:

Very Dissatisfied

Dissatisfied

Neither Satisfied nor Dissatisfied

Satisfied

Very Satisfied


a. 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 mark how much you disagree or agree about each of the statements that you read.

For example, some questions look like this:



Strongly Disagree

Disagree

Neither Agree nor Disagree

Agree

Strongly Agree

c. Men get colon cancer more often than women



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





SECTION A: Tell Us About Yourself





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





A1.

What is your age?


AGE





A2.

What is your sex?


  • Male

  • Female





A3.

Do you consider yourself: Please only one.


  • Hispanic or Latino

  • Not Hispanic or Latino





A4.

What is your race? Please one or more.


  • White

  • Black or African American

  • Asian

  • American Indian or Alaska Native

  • Native Hawaiian or Other Pacific Islander





A5.

What language do you usually speak at home?


  • English

  • Spanish

  • Other (Please specify):





A6.

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’s Degree

  • College graduate with BA or BS Degree

  • Graduate/professional education and/or Degree





A7.

A re you employed?


  • Yes (If Yes, please answer Question A7a.)

  • No (If No, please go to Question A8.)






A7a. Are you employed full time or part time?


  • Full Time

  • Part Time



A8.

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


  • Less than $10,000

  • $10,000 to $19,000

  • $20,000 to $34,000

  • $35,000 to $49,000

  • $50,000 to $74,000

  • $75,000 +

  • Don’t Know





Next are some questions about the doctor you saw for your last routine check-up.





A9.

How long have you been a patient of the doctor you saw for your last routine check-up?


Years Months





A10.

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


How often have you seen this doctor? Please 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 routine check-ups.

  • I get most of my care from another doctor in this same office.

  • I get most of my care from another doctor’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)



SECTION B: 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. To answer the following questions, please write in or check () the best answer.





B1.

In general, would you say that your health is:


  • Excellent

  • Very good

  • Good

  • Fair

  • Poor





B2.

H ave you ever been diagnosed with cancer?


  • Yes (If Yes, please answer Question B2a)

  • No (If No, please go to Question B3)






B2a. What type of cancer? (Please specify):







B3.

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


  • Yes

  • No

  • Don’t Know


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


_____________ ____________

_____________ ____________

_____________ ____________

_____________ ____________

_____________ ____________



B4.

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


  • Yes

  • No

  • Don’t Know





B5.

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 nor unlikely

  • Likely

  • Extremely likely





B6.

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





SECTION C: Experience with Tests and Screenings





Now we are interested in your experience talking with your doctor about disease prevention, and having different screening tests, including colon cancer screening. Please answer the following questions.





C1.

Please check () below if your doctor talked to you about any of the following issues at your last check-up AND / OR anytime in the last five years.




Talked about at last check-up?

Talked about in the
last 5 years?


Did your doctor talk to you about:


Yes

No

Yes

No


a. Smoking


b. Exercise or physical activity


c. Dietary and nutrition habits


d. Colon cancer screening


FOR WOMEN:






e. Breast cancer screening


f. Cervical cancer screening


FOR MEN:






g. Prostate cancer screening



C2.

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.




Done or ordered at last check-up?

Done or ordered in the last 5 years?



Did your doctor order any of the following tests?


Yes

No

Yes

No


a. Blood pressure check


b. Cholesterol test (blood test)


c. Rectal exam for colon cancer (i.e., “finger” test)


d. FOBT (stool card test)


e. Flexible sigmoidoscopy


f. Colonoscopy


FOR WOMEN






g. Pap smear


h. Breast exam


i. Mammogram (breast x-ray)


FOR MEN






j. Prostate specific antigen blood test (PSA)





C3.

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


  • Yes

  • No





C4.

Have you heard of the following tests for colon cancer?


Yes

No



a. Rectal exam (i.e., “finger test) (“finger” test)



b. Fecal occult blood test (FOBT) or Hemoccult test (stool card test)



c. Fecal immunochemical test (FIT)



d. Flexible sigmoidoscopy



e. Colonoscopy



f. Virtual colonoscopy



g. Barium enema




C5.

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


a. Rectal exam (“finger” test)


b. Fecal occult blood test (FOBT) or Hemoccult (stool card test)


c. Fecal immunochemical test (FIT)


d. Flexibly sigmoidoscopy


e. Colonoscopy


f. Virtual colonoscopy


g. Barium enema






SECTION D: Colon Cancer Screening Experience





Now we are interested in your experience with FOBT, Flexible Sigmoidoscopy, Colonoscopy, and Barium Enema.






FOBT stands for a Fecal Occult Blood Test which is a set of cards to take home to collect 3 stool samples. 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) See example card below.




Flexible Sigmoidoscopy is also called a ‘Flex Sig’. A doctor or nurse practitioner inserts a flexible tube into your rectum (or bottom) to check for bowel problems and colon cancer. You have a preparation that you do at home. The Flex Sig is done in a clinic without a sedative. You have to have someone drive you home, and you may have to miss work for the day.


Colonoscopy is a medical procedure which is done in a clinic. It allows for a full viewing of the colon. You have a preparation that you do at home, and during the procedure you are given a sedative. A doctor inserts a flexible tube into your rectum (or bottom) to check for bowel problems and colon cancer. You have to have someone drive you home, and you may have to miss work for the day.


Barium Enema or double contrast barium enema is an x-ray of your colon. You are given an enema with a liquid called barium. Then the doctor takes an x-ray. The barium makes it easy for the doctor to see the outline of your colon on the x-ray to check for polyps or other problems. You have to have someone drive you home, and you may have to miss work for the day.




D1.

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


a. FOBT


b. Flexible Sigmoidoscopy


c. Colonoscopy


d. Barium Enema





Fecal Occult Blood Test (FOBT) (Please see the description on page 5.)

D2.

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


In the last year, were you given an FOBT kit to take home?


  • Yes (Continue)

  • No (If No, please go to Question D9)





D3.

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


When you were given the kit, did someone at your doctor’s office give you instructions on how to use the FOBT cards?


  • Yes

  • No





D4.

Were you reminded to return the cards?


After you got home, did someone from your doctor’s office remind you to return the cards?


  • Yes

  • No









D5.


How satisfied were are 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 or nurse’s explanation of the procedures to do the FOBT test





D6.

Did you return the cards?


  • Yes (Continue)

  • No (If No, please go to Question D9)





D7.

Did you get the results?


How did you get the results?


  • Phone call from the doctor’s office

  • Letter from the doctor’s office

  • In person

  • Never got the results










D8.

How satisfied were you with…

How satisfied were you with: (Please check the best answer.)

Very Dissatisfied

Dissatisfied

Neither Satisfied nor Dissatisfied

Satisfied

Very Satisfied


a. Dietary restrictions for the FOBT


b. Overall preparations for the FOBT


c. Collection of the stool sample


d. Follow up procedures Sending the sample to the clinic or lab


e. Receiving the FOBT results The clinic or lab contacting you about your FOBT test results


f. Explanation of the FOBT test results





Flexible Sigmoidoscopy (Flex Sig) (Please see the description on page 5.)

D9.

In the past 5 years, did your doctor
recommend a Flex Sig screening?


  • Yes (Continue)

  • No (If No, please go to Question D15)





D10.

How satisfied were you with…


When your doctor recommended the 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’s office


b. Your doctor’s explanation of the Flex Sig screening





D11.

Did you schedule an appointment for a Flex Sig?


  • Yes (Continue)

  • No (If No, please go to Question D15)





D12.

Did you have the screening?


  • Yes (Continue)

  • No (If No, please go to Question D15)





D13.

Did you get the results?


How did you get the results?


Phone call from:

    • Physician

    • Nurse

    • Medical Assistant

Letter from:

    • Physician

    • Clinic

    • Lab


  • Phone call from the doctor’s office

  • Letter from the doctor’s office

  • In person

  • Never got the results









D14.

How satisfied were you with…

When you had the Flex Sig, how satisfied were you with:

Very Dissatisfied

Dissatisfied

Neither Satisfied nor Dissatisfied

Satisfied

Very Satisfied


a. Dietary restrictions for the Flex Sig


b. The use of a laxative or enema


c. Overall preparations for the Flex Sig


d. The convenience of the screening location


e. How the screening specialist treated you


f. Your comfort during the Flex Sig procedure


g. The doctor or clinic contacting you about your Flex Sig screening results


h. Explanation of the Flex Sig screening results





Colonoscopy (Please see the description on page 5)

D15.

In the past 10 years, did your doctor recommend a Colonoscopy screening?


  • Yes (Continue)

  • No (If No, please go to Section E)





D16.

How satisfied were you with…

When your doctor recommended the Colonoscopy, 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. Your doctor’s explanation of Colonoscopy screening





D17.

Did you or someone at the clinic schedule a Colonoscopy appointment for you?


  • Yes (Continue)

  • No (If No, please go to Section E)





D18.

Did you have the screening?


  • Yes (Continue)

  • No (If No, please go to Section E)





D19.

Did you get the results?


How did you get the results?



Phone call from:

    • Physician

    • Nurse

    • Medical Assistant

Letter from:

    • Physician

    • Clinic

    • Lab


  • Phone call from the doctor’s office

  • Letter from the doctor’s office

  • In person

  • Never got the results





D20.

How satisfied were you with…

When you had the Colonoscopy, how satisfied were you with:

Very Dissatisfied

Dissatisfied

Neither Satisfied nor Dissatisfied

Satisfied

Very Satisfied


a. Dietary restrictions for the Colonoscopy


b. The use of a laxative or enema


c. Overall preparations for the Colonoscopy


d. The convenience of the screening location


e. How the screening specialist treated you


f. Your comfort during the Colonoscopy procedure


g. The doctor or clinic contacting you about your Colonoscopy test results


h. Explanation of the Colonoscopy test results





SECTION E: Your Opinions About Colon Cancer





E1.

For each of the following statements, please check () if you disagree, agree, or you 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 can be cured


e. Blood in your stool means you have colon cancer for sure


f. A diet with a lot of roughage fiber, 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

If you have colon cancer, you would have symptoms






SECTION F: Your Opinions About Colon Cancer Screening






F1.

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 hard to do because my doctor is not easy to talk to


j. is a waste of time because when I ask questions, my doctor doesn’t have answers


k. would be embarrassing


Is something the doctor won’t talk about because my insurance doesn’t cover it



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 statement below about FOBT (stool cards).






F2.

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



Strongly
Disagree

Disagree

Neither
Agree nor
Disagree

Agree

Strongly
Agree


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 not needed if I have had it once before


l. is nice to be able to do in the privacy of my own home


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


q. is unnecessary if I have a Flex Sig or a Colonoscopy








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

Please check () how strongly you disagree or agree with each statement below about Colonoscopy.



Removed entire question about Flexible Sigmoidoscopy screening test



F3.

Having a Colonoscopy screening 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



Strongly
Disagree

Disagree

Neither
Agree nor
Disagree

Agree

Strongly
Agree


h. is something I am too busy to do


i. would protect my health so I can take better care of my 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 (fightening, scary) scary


o. would be uncomfortable


p. is not needed if I have 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 screening, your opinions are important to us.





F4.

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

Strongly
Disagree

Disagree

Neither
Agree nor
Disagree

Agree

Strongly
Agree


a. Fitting a Colonoscopy screening test into my schedule is hard


b. I have trouble taking time off from work or changing my schedule to do the Colonoscopy test


c. Colon cancer screening is a way for doctors and insurers to make money


d. I would do the FOBT kit if my doctor tells me to


e. I would have the Flex Sig screening if my doctor tells me to


f. I would have the Colonoscopy screening if my doctor tells me to


g. My doctor never always talks about screening for colon cancer



Strongly
Disagree

Disagree

Neither
Agree nor
Disagree

Agree

Strongly
Agree


h. My doctor never always talks about FOBT


i. My doctor never always talks about Colonoscopy


Fitting a flex sig screening into my schedule is hard


Medicare pays for flex sig screening


Medicare pays for colonoscopy screening


My insurance or health plan pays for flex sig screening


My insurance or health plan pays for colonoscopy screening


My doctor never talks about flex sig



SECTION G: Social Support





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





G1.

Discussing colon cancer screening with my doctor is something that is encouraged by:

Strongly
Disagree

Disagree

Neither
Agree nor
Disagree

Agree

Strongly
Agree


a. My spouse or partner NA


b. My family


c. My friends


d. My doctor or nurse


e. The popular media (TV, radio, magazines)





G2.

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 NA


b. My family


c. My friends


d. My doctor or nurse


e. The popular media (TV, radio, magazines)





G3.

My having a Colonoscopy screening is something that is encouraged by:

Strongly
Disagree

Disagree

Neither
Agree nor
Disagree

Agree

Strongly
Agree


a. My spouse or partner NA


b. My family


c. My friends


d. My doctor or nurse


e. The popular media (TV, radio, magazines)


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)




SECTION H: Plans to Talk about Colon Cancer or Get Screened





H1.

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

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 get screened for colon cancer in the next year


c. I plan to do an FOBT after my next check-up for colon cancer screening in the next year


d. I plan to have a Colonoscopy after my next check-up for colon cancer screening in the next year


e. I plan to have a Flex Sig after my next check-up for colon cancer screening in the next year


f. I plan to do whatever my doctor tells me to do for colon cancer screening in the next year




Thank you very much for completing this survey



Please place your survey in the enclosed stamped envelope

and drop it in the mail for us!



Patient ID


File Typeapplication/msword
File TitleAn Intervention and Evaluation
AuthorDonetta Ghosh
Last Modified Bycww6
File Modified2009-04-08
File Created2009-03-24

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