Attachment 4b - Revised Patient Post-Intervention Survey

S creening and Prevention Survey

Form Approved

OMB Control No: 0920-0769

Expiration Date: 03/31/2011

Screening and Prevention 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 talking about colon cancer screening. Even if you have not talked to your doctor or provider about colon cancer screening, or even if you have not been screened, please still fill out the survey. Your opinions are important to us!

Completing this survey will help make programs that help your provider and others give better patient care. You may have received a similar survey about colon cancer screening in the past. Please complete this new survey whether or not you filled out a similar one a few moths ago.

You were selected to receive this survey because you are age 50 or older and you visited an ABQ clinic in the past 3 months. You are being paid $10 to compensate your for your time and effort.

 Please do not have other family members fill out the survey that has been addressed to you.

Your answers are strictly private.

 Please do not put your name on your 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

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.

[ Please also mail your signed HIPAA form which allows us to include your survey answers in our final summary. ABQ HP/Lovelace only]

Thank you!

Instructions and Question Examples

This survey has several ways it asks questions. When any question asks about “your provider”, it means the doctor or medical practitioner who provides your routine primary care. 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 or 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, the questions look like this:

A3. How satisfied were you with…..
Neither
Very Satisfied Nor Very

Dissatisfied Dissatisfied Dissatisfied Satisfied 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, the questions look like this:

Neither
Strongly Agree nor Strongly

Disagree Disagree Disagree Agree 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 let 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. Are you employed?  Yes (If Yes, please answer Question A7a.)

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

A 7a. 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 primary care provider you most recently saw..

A9. How long have you been a patient of the primary care provider you most recently saw?

Years Months

A10. How often have you seen this provider? Please  all that apply.

 I am a new patient of this provider and I have only visited once or twice.

 I get most of my care from this provider.

 This doctor does most of my routine check-ups.

 I get most of my care from another provider in this same office.

 I get most of my care from another provider’s office.

 Other (Please specify): _________________________________

SECTION B: Experience with Tests and Screenings

Now we are interested in your experience talking with your primary care provider about disease prevention, and having different screening tests, including colon cancer screening. When we use the term colon cancer, we mean cancer of the colon, rectum, or bowel. It is sometimes called colorectal cancerl. Please answer the following questions.

B1. Please check () below if your primary care provider talked to you about any of the following at your last visit AND / OR some other time in the last five years.

Did your provider talk to you about:
	Talked about at last visit?		Talked about in the last 5 years?
	Yes	No	Yes	No
a. Smoking				
b. Exercise or physical activity				
c. Dietary and nutritional habits				
d. Colon cancer screening				
FOR WOMEN:
e. Breast cancer screening				
f. Cervical cancer screening				
FOR MEN:
g. Prostate cancer screening				

B2. Please check () below if your primary care provider did or ordered the following tests at your last visit AND / OR some other time in the last five years.
	Done or Ordered at last visit?		Done or Ordered in the last 5 years?
Did your provider 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)				

B3. Have you ever had any bowel symptoms (i.e., blood in the stool, changes in bowel movements) that caused your provider to suggest you be tested for colon cancer?

 Yes

 No

B4. 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		

B5. 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. Flexible sigmoidoscopy						
e. Colonoscopy						
f. Virtual colonoscopy						
g. Barium enema						

Section C: Personal Cancer Experience and Family History of Colon Cancer

Please answer the following questions about colon cancer. To answer the following questions, please write in or check () the best answer.

C5. 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 or unlikely

 Likely

 Extremely likely

C6. 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

C1. In general, would you say that your health is….

 Excellent

 Very good

 Good

 Fair

 Poor

C 2. Have you ever been diagnosed with cancer?  Yes (if Yes, please answer Question C2a)

 No (If No, please answer Question C3)

C2a. What type of cancer? (Please specify): __________________________________

_______________________________________________________________________

C3. Has anyone in your immediate family (i.e., spouse, children, parents, siblings) ever been diagnosed with cancer?

 Yes

 No

 Don’t Know

C4. Has anyone in your immediate family (i.e., spouse, children, parents, siblings) ever been diagnosed with colon cancer?

 Yes

 No

 Don’t Know

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.	Where have you received information about colon cancer screening tests? Please check () all that apply.	Yes	No
	a. Brochure in the clinic		
	b. Your provider		
	c. Nurse or medical assistant		
	d. Work wellness program		
	e. Information packet mailed to you		
	f. Media (TV, magazines, radio, etc.)		
	g. Friends or family		
	h. Other (Specify: __________________________)		

D2. 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	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							

Now we are interested in your experience with colon cancer screening at your last primary care visit and in the past few years.

D3. Did you receive any information about colorectal cancer screening in the mail, before your last primary care visit?

 Yes (Continue)

 No (If No, go to Question D6)

D4. Did you read through the information about colorectal cancer screening before your appointment?

 Yes

 No

D5.

Did you find the information about colon cancer screening to be helpful?

Yes No

D6. Did you and your provider talk about colon cancer screening at your last primary care visit?

• Yes (Continue)

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

• Yes (Continue)

No (If No, please go to Question D9)

D7. Who started the conversation about colon cancer screening at your last primary care visit? Please  only one.

 You

 Your provider

 One of clinic staff

D8. Please check how strongly you agree or disagree with the statements about your colon cancer screening discussion at your last primary care visit.

	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
a. I felt that colon cancer screening was important for me.					
b. My provider listened carefully to what I had to say about colon cancer screening.					
c. My provider answered all my questions about colon cancer screening.					
d. I felt that colon screening could prevent colorectal cancer.					
e. I felt understood					
f. I felt comfortable expressing my feelings about colon cancer screening					
g. My provider acted like I was wasting his or her time.					
h. I felt comfortable asking questions about colon cancer screening					
i. I felt pressured to get screened					
j. I wanted the conversation to end					
k. At the end of the discussion I wanted to get screened for colon cancer					

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

D9.	At your last primary care visit, did your provider talk with you about colon cancer screening with an FOBT kit?		Yes (Continue) No (If No, please go to Question D12)
D10.	At your last primary care visit, did your provider recommend that you get screened with an FOBT kit?		Yes (Continue) No (If No, please go to Question D12)
D11.	At your last primary care visit, were you given an FOBT kit to take home?		Yes (If Yes, please go to Question D13) No (Continue)

.

D12. In the last year, were you given an FOBT kit to take home?

 Yes (Continue)

 No (If No, go to Question D20)

D13. When you were given the kit, did someone at your provider’s office give you instructions on how to use the FOBT cards?

 Yes

 No

D14. After you got home, did someone from your provider’s office remind you to return the cards?

 Yes

 No

D16. Did you return the FOBT cards?

 Yes (Continue)

 No (If No, please go to Question D20) _____________________________________

D17. How did you get the results?

 Phone call from the provider’s office

Letter from the provider’s office

In person

Never go the results

D15. How satisfied were you with…..	Very Dissatisfied	Dissatisfied	Neither Satisfied nor Dissatisfied	Satisfied	Very Satisfied
a. Colon cancer information given by your provider’s office					
b. The provider’s explanation of the procedures to do the FOBT test					
c. The instructions on how to do the FOBT					
d. Getting help from your clinic if you had questions about completing the FOBT kit					
D18. How satisfied were you with (Please check the best answer)	Very Dissatisfied	Dissatisfied	Neither Satisfied nor Dissatisfied	Satisfied	Very Satisfied
a. Dietary restrictions					
b. Overall preparations for the FOBT					
c. Completing the FOBT kit at home					
d. Collection of the stool sample					
e. Sending the sample to the clinic or lab					
f. The clinic or lab contacting you about your FOBT rest results					
g. Explanation of the FOBT test results					

D19.	What motivated you to get screened with the FOBT? Please check () all that apply.	Yes	No
	a. Talking with your provider		
	b. Nurse or medical assistant		
	c. Reading about colon cancer screening		
	d. Friends or family members		
	e. Colon cancer screening materials received in the mail		
	f. Hearing about colon cancer screening in the media		
	g. Work wellness program		
	h. Other (Specify: __________________________)		

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

D20.	At your last primary care visit, did your provider talk with you about Flex Sig screening?		Yes (Continue) No (If No, please go to Question D22)
D21.	At your last primary care visit, did your provider recommend Flex Sig screening?		Yes (If Yes, please go to Question D23) No (Continue)

. D22. In the past 5 years did your doctor recommend a Flex Sig screening?

 Yes (Continue)

 No (If No, go to Question D25)

D23. Did you schedule a Flex Sig appointment?

 Yes (Continue)

 No (If No, go to Question D25)__

D24.. Did you have the screening?

 Yes

 No

Colonoscopy (Please see the description on page X.)

D25.	At your last primary care visit, did your provider talk with you about Colonoscopy screening?		Yes (Continue) No (If No, please go to Question D27)
D26.	At your last primary care visit, did your provider recommend Colonoscopy screening?		Yes (If Yes, please go to Question D28) No (Continue)

D27. In the past 10 years did your provider recommend a Colonoscopy screening?

 Yes (Continue)

 No (If No, please go to section E)__

D29. Did you or someone at the clinic schedule a Colonoscopy appointment for you?

 Yes (Continue)

 No (If No, please go to section E)_

D30.

Did you receive a call or mail to remind you to keep your Colonoscopy appointment?

Yes No

D31 Did you have the screening?

• Yes (Continue)

• No, I am still scheduled (If No, please go to Section E)

No, I decided not to have it (If No, please go to Section E)

D32. How did you get the results?

• Phone call from the provider’s office

• Letter from the provider’s office

• In person

Never got the results

D28. When your provider 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 provider’s office					
b. Your provider’s explanation of the Colonoscopy screening					

D33.	When you had the Colonoscopy, how satisfied were you with:	Very Dissatisfied	Dissatisfied	Neither Satisfied nor Dissatisfied	Satisfied	Very Satisfied
	a. The process of making the Colonoscopy appointment					
	b. The time interval between making the appointment and the actual screening appointment					
	c. Dietary restrictions for the Colonoscopy					
	d. Getting help from your clinic if you had questions about colonoscopy					
	e. The use of laxative or enema					
	f. Overall preparations for the Colonoscopy					
	g. The convenience of the screening location					
	h. How the screening specialist treated you					
	i. Your comfort during the Colonoscopy procedure					
	j. The doctor or clinic contacting you about your Colonoscopy test results					
	k. Explanation of the Colonoscopy test results					

D34.	What motivated you to get screened by Colonoscopy? Please check () all that apply.	Yes	No
	a. Talking with your provider		
	b. Nurse or medical assistant		
	c. Reading about colon cancer screening		
	d. Friends or family members		
	e. Colon cancer screening materials received in the mail		
	f. Hearing about colon cancer screening in the media		
	g. Work wellness program		
	h. Other (Specify: __________________________)		

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 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 provider:

	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, the 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 opinion 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.					
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 something I am sure I can do					
j. is not necessary at my age.					
k. would be awful (disgusting) because I have to handle my stool.					
l. is a test I like being able to do in the privacy of my own home.					
m. is not needed if I’ve had it once before.					
n. involves too much hassle because I have to prepare for the test.					
o. is something I don’t know how to do correctly.					
p. is a waste of time because the test is not accurate.					
q. is unnecessary for women because only men are at risk for colon cancer					
r. would make me worry about the results					
s. is unnecessary if I have a Flex Sig or a Colonoscopy					

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

Please check () how strongly you disagree or agree with each opinion 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					
h. is something I am too busy to do.					
i. is something I am sure I can do					
j. would protect my health so I can take better care of family					
k. is not as important as screening tests for other diseases and cancers					
l. is a hassle because the wait for the appointment is too long					
m. is not necessary at my age					
n. would be embarrassing					
o. would be scary					
p. would be uncomfortable					
q. is not needed if I have had it once before					
r. involves too much hassle because I have to prepare for the test					
s. is unnecessary for women because only men are at risk for colon cancer					
t. would make me worry about the results					
u. is hard because I would have to go to another clinic for the test					

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 provider tells me to					
e. I would do the Flex Sig screening if my provider tells me to					
f. I would do the Colonoscopy screening if my provider tells me to					
g. My provider always talks about screening for colon cancer					
h. My provider always talks about FOBT					
i. My provider always talks about Colonoscopy					

SECTION G: Social Support

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

G1. Discussing colorectal cancer screening with my provider 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 provider 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 provider or nurse					
e. the media (TV, radio, magazines)					

D3. 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 provider 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 provider at my next primary care visit.					
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 Flex Sig for colon cancer screening in the next year					
e. I plan have a Colonoscopy 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					

Please let us know if you have any additional comments:

Thank you very much for completing This survey

Please place it in the enclosed stamped envelope,

along with your signed HIPAA authorization form [ABQ HP/Lovelace only],

and drop it in the mail for us!

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