Form #2 Attachment C - Health Care Professional Questionnaire

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Form Approved
OMB No. 0935-0179
Exp. Date 07/31/2014

urvey for Health Care Professionals

1. Do you see patients that are Latino and speak Spanish? Circle one.

• Yes

• No

• My patients are Latino and speak English only

• My patients are not Latino and speak English only

2. What are the biggest challenges for the patients you serve to adhere to their treatment plan? Circle up to two, but please indicate which is more important, by placing #1 or #2 next to each item.

• Cost

• Getting medication

• Taking the medicine

• Side effects

• Getting to a clinician regularly

• Changes to diet

• Getting to a healthy weight

• Cultural

• Other ________________

3. Besides from you, from where do your patients obtain their information on diabetes and healthcare information in general? Circle one.

• Media

• Internet

• Library

• Mostly me, and I provide their first information

• Only me

• Family or friends

• Fairs or community events

• Church

4. In your opinion, how effective is the telenovela format to communicate information about diabetes? Circle one.

• Very appropriate

• Appropriate

• Not appropriate

• Appropriate, but only for Latino patients

5. Is the telenovela information presented in a natural, logical manner that your patients can follow? Circle one.

• Yes

• No

6. A. Is there anything you particularly like or dislike about the telenovela with regard to: (Place an “X” under the column of your choice for the items that apply)

Like Dislike

• Characters

• Storyline

• Medical information

• Setting

7. If you had the chance to “add” or “delete” information to the videonovela, what would that be: Please write below briefly

Add:

Delete:

8. After watching this information, do you think your patients are more likely to ask questions and adhere to their medication or treatment plans? Circle one.

• Yes

• No

• Not sure

9. A. Circle one. Is each episode of the telenovela:

• Too short

• Just right

• Too long

B. Circle one. Do you think there should be:

• More episodes

• Fewer episodes

• Why? ___________________________

10. Circle any that apply. Would you recommend the videonovela to:

• Family member

• Friend

• Another educator

• Clinician

• Other ___________

11. Where would it be appropriate to watch this telenovela? Circle any that apply.

• Doctor’s office

• Diabetes Center or Endocrinology Department

• Television

• Internet/computer

• Mobile phone

• Other ______________________________

12. What other topic(s) do you think might be useful for patients to see in a telenovela format? Circle any that apply.

• Managing heart disease

• Being a caregiver

• Treating Depression

• Other __________________________

This question will be used only for statistical purposes and will not be used to identify or contact you.

13. Circle one: Are you

• Nurse (RN, NP, LPN or other)

• Physician

• Dietitian

• Medical Assistant

• Other healthcare professional_____________

Thanks for your collaboration. If you are interested in ordering free copies of the DVD or any of the consumer brochures (in English or Spanish) seen in the videonovela, please send an email to [email protected].

Public reporting burden for this collection of information is estimated to average 10 minutes per response, the estimated time required to complete the survey. 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: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-0179) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.