Attach 4a - Revised Patient Pre-Intervention Survey

Form Approved

OMB Control No: 0920-0769

Expiration Date: 03/31/2011

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 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 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):

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
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 (“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.

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

Yes (Continue) No (If No, please go to Question D9)

D3.

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.

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

Yes No

D5.

How satisfied 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.

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: (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. Sending the sample to the clinic or lab							
	e. 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.	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.	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

D14.	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.	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.	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

D20.	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 fiber, like fruits, vegetables, and grains, may reduce your chances of getting colon cancer								
	g. 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							
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.
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 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 always talks about screening for colon cancer							
		Strongly Disagree			Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
	h. My doctor always talks about FOBT							
	i. My doctor always talks about Colonoscopy							
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 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 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 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 for colon cancer screening in the next year							
	d. I plan to have a Colonoscopy for colon cancer screening in the next year							
	e. I plan to have a Flex Sig 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