Form 002_BFWHWEmWell_Di 002_BFWHWEmWell_Dist

Bright Futures for Women's Health and Wellness

BFWHW Distributor Survey Tool

Bright Futures for Women's Health and Wellness - Distributor Survey

OMB: 0915-0329

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Bright Futures for Women’s Health and Wellness Initiative
Survey for Individuals Distributing the Bright Futures for Women’s Health and Wellness:
Emotional Wellness Guides

DRAFT
Please answer the following questions:
1. Please indicate your sex:
 Male
 Female
2. Please indicate your age group:
 18-24
 25-44
 45-64
 65+
3. Are you Hispanic or Latina?
 Yes
 No
4. Which one of the following would you say is
your race?
 White
 Black
 American Indian or Alaska Native
 Asian
 Native Hawaiian or other Pacific Islander
 Two or more races
5. What is your role in your organization?
 Health care provider
 Counselor
 Social worker
 Outreach worker
 Peer educator/Promotora
 Other________________________
6. What is your primary professional qualification?
 Medical Doctor
 Licensed nurse
 Licensed social worker
 Midwife
 Psychologist
 Licensed Professional Counselor
 Advanced Practice Nurse
 Other ________________________

7. How many years of experience do you have in
your current profession?
 Less than 3 years
 3 – 5 years
 6 – 10 years
 11– 20 years
 More than 20 years
8. What types of services do you provide (check all
that apply)?
 Prenatal care
 HIV/AIDS treatment
 Routine medical care
 Emotional health care
 Social support or case management services
 Other_____________________________
9. Approximately how many individual women do
you see each month?
 1-10
 11-25
 26-50
 More than 50
Please describe the women to whom you provide
services:
10. Approximately what percentage of the women
you see fall into each of these age groups?
Under 18 ____%
18-24 ____%
25-44 ____%
45-64 ____%
65+ ____%
11. Approximately what percentage of the women
you see are in each of these race/ethnic groups?

Public Burden Statement: 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. The OMB control number for this project is 0915-xxxx.
Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for
reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing
this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-33, Rockville, Maryland, 20857.

Hispanic ____%
White ____%
Black ____%
American Indian or Alaska Native____%
Asian____%
Native Hawaiian or other Pacific Islander___%
Two or more races ____%
12. How often do the women you see talk to you
about emotional health issues or concerns?
 Very often
 Somewhat often
 Occasionally
 Rarely
13. What types of emotional health issues or
concerns are most frequently reported to you by
the women you see (check all that apply)?
 Depression
 Family or relationship problems
 Loneliness
 Substance abuse
 Anxiety
 Other ______________________
14. How comfortable are you talking about
emotional health and well-being with the
women you see?
 Very comfortable
 Mostly comfortable
 Somewhat comfortable
 Somewhat uncomfortable
 Very uncomfortable
15. Were you aware of the Bright Futures for
Women’s Health and Wellness (BFWHW)
program or the consumer guides prior to this
evaluation of the guides?
 Yes
 No
16. Did you distribute any of the BFWHW Emotional
Wellness Guide guides prior to this evaluation
of these guides?
 Yes (check all that apply)
___ Physical Activity and Healthy Eating Guides

___ Emotional Wellness Guides
 No
 Unsure
17. Approximately how many women have you
given copies of the BFWHW Adult Woman’s
Guide to Emotional Wellness since this
evaluation of the guides began?
0
 1-25
 26-50
 51-100
 More than 100
18. Approximately how many women have you
given copies of the BFWHW Young Woman’s
Guide to Emotional Wellness since this
evaluation of the guides began?
0
 1-25
 26-50
 51-100
 More than 100
19. To whom and under what circumstances do you
give the BFWHW Emotional Wellness Guides?
 Only to women who express concerns about
emotional wellness
 Only to women who participate in a certain
program or receive a certain type of service.
Please specify: _________________________
_______________________________________
 Most of the women I have seen since the
evaluation began
 All the women I have seen since the
evaluation began
20. When you give women the BFWHW Emotional
Wellness Guides, how extensively do you
usually go through it with them (e.g., explaining,
talking about it, and/or answering questions)?
 I spend a minute or two explaining what it is
and why I’m giving it to them
 I flip through it with them for several minutes
and point out one or two points of interest

 I spend 10 or more minutes walking through
the whole Guide with them and answering
questions
 It varies depending on the circumstance (e.g.
depends on whether the woman raised any
issues of emotional health herself, how
many questions she asks, what type of
appointment)
 Other ___________________________
21. Do you think the Woman’s Guide contains advice
that the adult women you see can use to feel
better about their lives?
 Yes, it contains very useful advice
 Yes, it contains mostly useful advice
 No, the advice is not very useful
 Unsure
 Not applicable (I did not distribute the
Woman’s Guide)
22. Do you think the Young Woman’s Guide contains
advice that the young women (under 18) you see
can use to feel better about their lives?
 Yes, it contains very useful advice
 Yes, it contains mostly useful advice
 No, the advice is not very useful
 Unsure
 Not applicable (I did not distribute the Young
Woman’s Guide)
23. How easy do you find it to explain and talk about
the BFWHW Emotional Wellness Guides to the
women you see?
 Very easy to explain and talk about
 Mostly easy to explain and talk about
 Somewhat easy to explain and talk about
 Somewhat difficult to explain and talk about
 Very difficult to explain and talk about
 I did not distribute the Women’s Guide
24. How relevant do you think the examples and
personal stories in the BFWHW Emotional
Wellness Guides are to the lives of the women
you serve?
 Very relevant
 Mostly relevant
 Somewhat relevant

 Somewhat irrelevant
 Very irrelevant
25. Since you have been distributing the BFWHW
Emotional Wellness Guides, do you discuss
emotional wellness with the women you serve
more often than before?
 Yes, much more often than before
 Yes, somewhat more often than before
 No, no difference
 Unsure
26. Since you have been distributing the BFWHW
Emotional Wellness Guides, have you referred
more women for further emotional health
services (on average)?
 Yes, I have referred many more women for
emotional health services on average than I
did before
 I have probably referred a few more women
for emotional health services on average
than I did before
 No, I have probably referred fewer women
for emotional health services on average
than I did before
 No, no difference
 Unsure
27. Would you recommend these BFWHW
Emotional Wellness Guides to other
professionals in your field?
 Yes
 No
 Unsure
28. Please circle whether you think the following
statements about the BFWHW Emotional
Wellness Guides are True or False:
T/F They are easy for the women I see to read
and understand.
T/F They are culturally appropriate for the
women I see.
T/F They help women to feel more comfortable
talking about emotional health and
wellbeing with me

T/F They help me to feel more comfortable
bringing up issues of emotional health and
wellbeing with the women I see
T/F They are too long.
T/F I often don’t have enough time to discuss
them with the women I see.
29. Do you plan to continue distributing these
BFWHW Emotional Wellness Guides as part of
your routine practice?
 Yes
 No
 Unsure
30. What other types of educational materials or
BFWHW Emotional Wellness Guides would you
find most useful in your practice?

31. Additional Comments:

Thank you for your participation!

File Type	application/pdf
File Title	Microsoft Word - Appendices_Bright Futures_NEW.DOC
Author	acash
File Modified	2009-07-21
File Created	2009-07-21