Assessing Adoption and Use of the Living a Balanced Life

Form Approved

OMB No. 0920-0864

Expiration date: 09/30/2013

Attachment 1

Assessing Adoption and Use of the Living a Balanced Life with Diabetes Toolkit

Consent Form and Survey

______________________________________________________________________

Public reporting burden of this collection of information is estimated to average 20 minutes, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the 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 (0920-0864).

Thank you for agreeing to complete this survey about your experience with the Living a Balanced Life with Diabetes Toolkit (The Toolkit). This survey will be used to assess how the Centers for Disease Control and Prevention (CDC) can best support health care professionals in using the Living a Balanced Life with Diabetes Toolkit to improve the lives of American Indian and Alaska Native Peoples with diabetes and/or at risk for heart disease.

The Living a Balanced Life with Diabetes Toolkit includes the following contents:

• Cover Letter

• Tip Sheets

• Depression Checklists

• List of Psychosocial Resources

• Indian Health Service Diabetes Depression Best Practice

• Suicide prevention hotline magnets

• Health for Native Life Magazine articles

• Wit and Wisdom Book and audio CD

We want to ask you a few questions about your use of The Toolkit and how you may have incorporated it into your work with American Indian and Alaska Native patients with diabetes.

Obtain Electronic Consent

Consent Statement –CDC’s National Diabetes Education Program (NDEP) is conducting this Web-based survey as part of its effort to assess CDC’s initiatives to reduce and control diabetes and heart disease. The purpose of this survey is to solicit feedback on the Living a Balanced Life with Diabetes Toolkit. Information collected from this survey will be used by NDEP to help improve existing and future products and promotions. The survey should take about 20 minutes of your time. Participation in the survey is voluntary. You may choose to end the survey at any time for any reason with no penalty, and may choose not to answer any questions at any time for any reason. You may choose not to participate in the survey for any reason. Your participation in the survey poses no risks to you. If you have any questions about this survey, or assessment, please contact Dr. Michelle Owens-Gary, Behavioral Scientist, at Phone: (770) 488-5014, E-mail: [email protected].

By clicking “Next” you give your consent to participate in this survey.

Living a Balanced Life with Diabetes Assessment Survey

1. What type of organization do you currently work at?

• Public Clinic/Community Health Center/Federally Qualified Health Center

• Public hospital

• Private hospital/clinic

• Other (Please specify). _______________________

2. What is your job title or role?

• Medical Doctor

• Nurse

• Psychologist

• Social Worker

• Health Educator

• Community Health Representative

• Other (Please specify). _______________________

3. Of the patients you see, about what percentage has diabetes? (Select one).

• None

• Less than half

• Half

• More than half

• All

• I’m not sure

4. Of the patients you see, about what percentage has hypertension? (Select one).

• None

• Less than half

• Half

• More than half

• All

• I’m not sure

5. From what online sources do you obtain patient education information about diabetes? (Select all that apply.)

• American Diabetes Association

• National Diabetes Education Program

• Centers for Disease Control and Prevention

• Indian Health Service

• National Institute of Diabetes and Digestive and Kidney Diseases

• A search engine

• Other (Please specify.) ___________________________

6. From what online sources do you obtain patient education information about hypertension? (Select all that apply).

• American Heart Association

• Centers for Disease Control and Prevention

• National Heart, Lung, and Blood Institute

• Other (Please specify.) ___________________________

7. At any time since October 2012 or within the past nine months, have you used any materials from the Living a Balanced Life with Diabetes Toolkit directly with American Indian/Alaska Native patients with diabetes during a patient encounter or support group to help address mental health issues?

• Yes

• No (If “no,” then SKIP to question 8).

8. Since October 2012, or within the last nine months, how often did you use any materials from the Balanced Life with Diabetes Toolkit over the last nine months?

• Daily

• Weekly

• Monthly

• As needed

• Never

9. Did you use the Tip Sheets from the Living a Balanced Life with Diabetes Toolkit

• Yes

• No (If “no,” then SKIP to question 10).

10. If you used any of the Tip Sheets, how or where did you use them? (Select all that apply.)

• Discussed them with a patient during a clinic visit

• Used them in a diabetes support group

• Provided them as resource materials for patients in the lobby or other areas

• Provided them to other health care professionals

• Other: _____________________

11. Did you use any of the Health for Native Life magazine articles on grief, anger, coping with diabetes?

• Yes

• No (If “no,” then SKIP to question 12).

12. If you used any of the Health for Native Life magazine articles, how or where did you use them? : (Select all that apply.)

• Discussed them with a patient during a clinic visit

• Used them in a diabetes support group

• Provided them as resource materials for patients in the lobby or other areas

• Provided them to other health care professionals

• Other (Please specify). ____________________________

13. Which other Living a Balanced Life with Diabetes Toolkit materials did you use? (Select all that apply.)

• All of these materials

• Wit and Wisdom Book

• Wit and Wisdom audio CD

• Depression Checklist

• The Patient Health Questionnaire-9

• Indian Health Service Diabetes Depression Best Practice

• Suicide Prevention Hotline magnets

• List of Psychosocial Resources

• None of these materials (If you answer “none of these materials,” then SKIP to question 14).

14. Of the materials that you said you used in Question 13, how did you use those Toolkit materials? (Select all that apply.)

• Discussed them with a patient during a clinic visit

• Used them in a diabetes support group

• Provided them as resource material for patients in the lobby or other areas

• Used them to develop or accompany other educational information

• Provided them to other health care professionals

• Conducted presentations and/or trainings

• Other (Please specify). ______________________

15. Which components of the Living a Balanced Life with Diabetes Toolkit were the most useful in addressing diabetes, mental health issues, and psychosocial issues? (Select all that apply.)

• All of these materials

• Wit and Wisdom book

• Wit and Wisdom audio CD

• Tip Sheets

• Depression Checklist

• The Patient Health Questionnaire-9

• Indian Health Service Diabetes Depression Best Practice

• Health for Native Life magazine articles on grief, anger, coping with diabetes

• Suicide Prevention Hotline magnets

• List of Psychosocial Resources

• None of these materials

16. Which components of the Living a Balanced Life with Diabetes Toolkit were the least useful in addressing diabetes, mental health issues, and psychosocial issues? (Select all that apply.)

• All of these materials

• Wit and Wisdom book

• Wit and Wisdom audio CD

• Tip Sheets

• Depression Checklist

• The Patient Health Questionnaire-9

• Indian Health Service Diabetes Depression Best Practice

• Health for Native Life magazine articles on grief, anger, coping with diabetes

• Suicide Prevention Hotline magnets

• List of Psychosocial Resources

• None of these materials

For each of the following statements, please indicate to what extent you agree or with the options being: Strongly Disagree, Disagree, Neither Agree nor Disagree, Agree, Strongly Agree.

17. I am satisfied with the Living a Balanced Life with Diabetes Toolkit.

18. The Living a Balanced Life with Diabetes Toolkit filled a resource gap for me or my organization.

19. The Living a Balanced Life with Diabetes Toolkit is a useful resource for disseminating information about diabetes and depression.

20. The Living a Balanced Life with Diabetes Toolkit increased my understanding of how depression and other psychosocial issues can impact diabetes management.

21. The Living a Balanced Life with Diabetes Toolkit helped me to address diabetes and psychosocial issues, like depression, in my practice with diabetes patients.

22. I plan to continue using The Living a Balanced Life with Diabetes Toolkit as a regular part of my practice to help patients cope with diabetes.

Please provide brief responses to the following three open-ended questions in the space below. There are no right or wrong answers. By providing detailed information, respondents will help CDC improve the Living a Balanced Life with Diabetes Toolkit and future disease prevention and health promotion products. (Limit: 100 words for each response)

23. What can the National Diabetes Education Program do to improve the Living a Balanced Life with Diabetes Toolkit? (100-word Limit)

_____________________________________________________________

24. What tools or other resources would you like for CDC to develop for patients with diabetes and psychosocial issues (100-word Limit) ______________________________________________________________

25. What tools or other resources from CDC would you for CDC to develop for patients with hypertension? (100-word Limit)

______________________________________________________________

Thank you for your time to complete this survey. If you have questions about this survey please contact Dr. Michelle Owens-Gary at [email protected].

26. Why have you not used materials from the Living a Balanced Life with Diabetes Toolkit? (Select all that apply.)

• I am not currently working with patients who have diabetes.

• My work does not focus on diabetes issues.

• The Toolkit materials are not appropriate for my needs.

• I was not aware that the Living a Balanced Life with Diabetes Toolkit existed.

• Other (Please specify). _________________

Thank you for your time to complete this survey. If you have questions about this survey please contact Dr. Michelle Owens-Gary at [email protected].