0379 - HCPS Supporting Statement A 06.21.19

Supporting Statement A

Health Center Patient Survey: Cognitive Pre-Testing to Support the Development of Survey Questions

OMB Control No. 0915-0379

1. Circumstances Making the Information Collection Necessary

Since the early 2000s, the Health Resources and Services Administration (HRSA) has conducted the Health Center Patient Survey (HCPS), a national survey of patients who receive services at health centers. The HCPS collects patient information about sociodemographic characteristics, health conditions, health behaviors, access to and utilization of health care services, and satisfaction with services received from HRSA funded health centers.

As part of the 2019 HCPS development, a small-scale pretest will be conducted to test main study implementation materials and procedures and identify potential issues with the questionnaire. The pretest will include 58 in-person Patient Survey cognitive interviews conducted in English, Spanish, Chinese (Mandarin and Cantonese), Vietnamese, and Filipino (Tagalog). The interviews will focus specifically on identifying problems with instrument question wording, clarity of instructions, and it will evaluate the timing and flow of the questions

The objective is to thoroughly test any changes to the survey instrument that was fielded in 2014. HRSA has determined that a total of 58 interviews are necessary to adequately test all new and revised questions, ensuring the congruency of questions and changes the skip patterns of questions or routing, in each of the five languages.

2. Purpose and Use of the Information Collection

With the introduction of new and modified content for the questionnaire and modified sampling methodology, a pretest for the 2019 HCPS is necessary to ensure that the recruitment and sampling plan are appropriate and survey questions are easily understood by survey respondents while meeting the scientific intent of the questions. Data collected during the pretest will be used to improve the clarity of the instructions, the wording of the survey items, the appropriateness of the response options, formatting, and the order of questions. Without these pretesting activities, recruitment may be negatively affected, and the quality of data collected from the main survey may be compromised, which could lead to increased burden time for respondents, decreased data quality, and less efficient data collection procedures.

3. Use of Improved Information Technology and Burden Reduction

All interviews for the pretest of the 2019 HCPS will be conducted through computer-assisted personal interviewing (CAPI). The CAPI approach offers several advantages that keep respondent burden at a minimum while ensuring high-quality data collection. First, the questionnaire is complex and involves numerous skip patterns and screening questions. These are easily and quickly performed by the computer upon completion of CAPI programming. In addition, the CAPI instrument detects erroneous and inconsistent responses, increasing data accuracy and validity. The use of CAPI will enable the interviews to be completed in less time, with reduced burden, and with more accuracy than a paper and pencil interview.

4. Efforts to Avoid Duplication and Use of Similar Information

The 2019 pre-test data collection aims to test any changes to the survey instrument that was fielded in 2014. The information collected in the cognitive interviews is unique and cannot be obtained elsewhere.

5. Impact on Small Businesses or Other Small Entities

This activity does not have a substantial impact on small entities or small businesses.

6. Consequences of Collecting the Information Less Frequently

The pre-test data collection is a one-time activity that supports the development of the 2019 HCPS. One-time activities cannot be conducted less frequently. The consequences of collecting this information less frequently would be to not conduct pretesting activities at all.

7. Special Circumstances Relating to the Guidelines in 5 CFR 1320.5

This information collection fully complies with 5 CFR 1320.5.

8. Comments in Response to the Federal Register Notice/Outside Consultation

As required by 5 CFR 1320.8(d), a 60-day Federal Register Notice was published in the Federal Register on February 21, 2017, vol. 82, No. 33; pp. 11230. No comments were received.

9. Explanation of any Payment/Gifts to Respondents

Respondents who participate in cognitive interviews will each receive an incentive payment for up to $25 cash or $25 cash equivalent. These incentives will be provided to respondents to encourage their participation. Particularly, this incentive is motivated by the following reasons:

• This project requires substantial participation by respondents with specific characteristics (e.g. health center patient populations whose primary spoken language is Spanish, Chinese, Vietnamese, or Tagalog). The more specific the characteristics, the more difficult it is to recruit eligible respondents.

• Cognitive interviews require an unusual level of mental effort. Respondents are asked to explain their mental processes as they hear the question, discuss its meaning and any ambiguities, and describe why they answered the questions the way they did. The interview will take approximately 75 minutes.

• Incentives will encourage respondents’ participation despite the substantial mental effort to answer questions and for any inconvenience related to traveling to the interview location, or the length of the interview.

• All respondents who start the interview will receive the incentive payment; those who are scheduled but do not show up to the interview will not be compensated.

Empirical survey research literature has examined the role of incentives in survey outcomes. This research has typically examined how incentives affect survey response rates, sample composition, item nonresponse, and measurement error.  For example, evidence supports offering an incentive is a critical element to predicting a respondent’s reaction to the survey request.¹ Additionally, incentives have been found to increase co-operation rates among certain groups: low-income and low-education groups, larger households and households with dependent children, minority ethnic groups, and younger respondents.²

10. Assurance of Confidentiality Provided to Respondents

Data for the pretest will be kept private to the extent allowed by law. Participating individuals and institutions will be informed that the information provided in the HCPS pretest will be kept secure and will be protected. Data collected will be in conformity with HRSA’s standards for protecting personally identifiable information on individuals. Consistent with the Privacy Act of 1974, interviewers will not provide respondent names or information about respondents to persons who are not part of the survey team. A privacy pledge will be collected from all personnel who will have access to individual identifiers.

All information collected during the pretest will be used for informational purposes to ensure that revised questions in the instrument are understood by participants. Data from these interviews will not be used in any other way, such as for publications or dissemination to the public. These data will be destroyed upon completion of the project.

11. Justification for Sensitive Questions

Sensitive questions are generally not included on the HCPS. However, it is possible that respondents may find some questions to be sensitive in nature. Federal regulations governing the administration of these questions, which might be viewed as sensitive due to personal or private information require (a) clear documentation of the need for such information as it relates to the primary purpose of the study, (b) provisions to respondents that clearly inform them of the voluntary nature of participation in the study, and (c) assurances of private treatment of responses. The following areas have been identified as potentially sensitive:

1. Questions on substance use and mental health status, thoughts about suicide, and perceived need for and use of mental health and substance abuse services may be perceived as sensitive by some respondents. This information is important for understanding the degree of unmet need for mental health and substance use disorder services.

2. Questions on HIV testing status and HIV infection status may be perceived as sensitive by some respondents. This information is important for understanding the experiences of health center patients in order to improve HIV related care delivery.

3. Questions on race/ethnicity may be perceived as sensitive. However, HRSA is specifically over-sampling certain racial groups, such as Asians, Pacific Islanders, etc. Accurate data on race/ethnicity is necessary to ensure that accurate coverage of these sub-populations to understand the extent of health disparity among health center patients.

4. Questions on sexual orientation and gender identity may be perceived as sensitive. HRSA has requested inclusion of these items to understand potential health disparities of these sub-populations.

5. Question on annual earnings and access and utilization of public assistance services. Accurate data is necessary for understanding the degree that earnings and public assistance services impact health center patients.

6. Questions about health status, such as questions on health conditions including cancer, hepatitis, high blood pressure, tuberculosis, among others. This information is important for understanding the health characteristics of health center patients and any degree of unmet need for services.

Prior to conducting the cognitive interview, respondents will be informed about the voluntary nature of their participation and the private treatment of their survey responses. Additionally, sensitive questions will be preceded by a statement read to the respondent that reiterates the points discussed during the informed consent administration. Respondents will understand that they have the right to refuse any question that they do not want to answer. They will also understand that refusing any question will not impact the care they currently receive from their health center or from any other government programs. Adolescent respondents, aged 13-17, will not be administered questions of a “sensitive” nature during the pretest.

Although some items are sensitive in nature, these responses will generate the data needed to drive research and develop quality improvement initiatives to support the health center patient population and address emerging public health needs.

12. Estimates of Annualized Hour and Cost Burden

The burden estimates for completing the 2019 HCPS pretest activities have been determined based on the experience of HRSA during the administration of the 2014 HCPS. All respondents will be administered the Patient Survey pretest questionnaire.

A patient screener will be administered to English and Spanish-speaking respondents who are recruited at the health centers to test the data collection procedures from receptionist referral to interviewer recruitment at the health center. A patient screener will not be administered to Tagalog, Chinese, or Vietnamese-speaking patients because they will be recruited through traditional methods (e.g. through advertisements posted in community forums) and not at the health center.

Estimated Annualized Burden Hours:

Table 1

Type of Collection	Number of Respondents	Responses per Respondent	Total Responses	Average Burden per Response (in hours)	Total Burden Hours
Patient Screening (English)	12	1	12	.17	2.04
Patient Screening (Spanish)	13	1	13	.17	2.21
Patient Screening: Short Blessed Scale3 (English)	1	1	1	.05	.05
Patient Screening: Short Blessed Scale (Spanish)	1	1	1	.05	.05
Patient Screening: Short Blessed Scale (Vietnamese)	1	1	1	.05	.05
Patient Screening: Short Blessed Scale (Chinese)	1	1	1	.05	.05
Patient Screening: Short Blessed Scale (Tagalog)	1	1	1	.05	.05
Patient Survey (English)	14	1	14	1.25	17.50
Patient Survey (Spanish)	14	1	14	1.25	17.50
Patient Survey (Vietnamese)	10	1	10	1.25	12.50
Patient Survey (Chinese)	10	1	10	1.25	12.50
Patient Survey (Tagalog)	10	1	10	1.25	12.50
Total	88		88		77.00

Estimated Annualized Burden Costs:

Table 2

Type of Respondent Based on Activity4	Total Hour Burden	Rate per Hour5 ($)	Total Cost ($)
Patient Screening	4.50	7.91	35.60
Patient Survey	72.50	7.91	573.48
Total – Survey	77.00		609.08

13. Estimates of Other Total Annual Cost Burden to Respondents or Recordkeepers/Capital Costs

Other than their time, there is no cost to respondents. The estimated burden cost for respondents’ time is shown in Section 12. Table 2.

14. Annualized Cost to the Federal Government

Estimated costs to the Federal government is approximately $59,660. (contract costs, 1 GS-13 – 10% time of work for two months) to monitor, review, and approve the pretest related activities.

Annual Costs to HRSA	Amount (in $)
HRSA FTE6	$1,778
Contract Costs RTI Labor (83.6%) Other Direct Costs (6.6%) Subcontractor (9.8%) Total (100%)	$48,376.38 $3,829.47 $5,676.00 $57,881.85
Annual Total	$59,659.85

15. Change in Burden

N/A

16. Plans for Tabulation, Publication, and Project Time Schedule

At this time, no statistical analysis will be conducted with the information collected from the pretest. At this time, no information collected will be published.

17. Reason(s) Display of OMB Expiration Date is Inappropriate

The OMB number and Expiration date will be displayed on every page of every form/instrument.

18. Exemptions to Certification for Paperwork Reduction Act Submissions

There are no exceptions to the certification.

1 Dillman, D. A. (2011). Internet, Phone, Mail and Mixed-Mode Surveys: The Tailored Design Method (4th ed). New York, NY: John Wiley & Sons.

2 Dodd, T. (1998) “Incentive Payments on Social Surveys: A Summary of Recent Research”. Survey Methodology Bulletin, 43: 23-27.

3 The Short Blessed Scale Form will be administered to respondents when a field interviewer believes that a person might be too cognitively impaired to participate the survey. According to 2014 survey experience, no Short Blessed Scale Form was needed for the pretest, and only 0.2% of eligible participants in the main survey were screened with this form.

4 All respondents are health center patients.

5 Based on the 2018 federal poverty guidelines for a family of 2 of $16,460. In 2017, approximately 70% of health center patients were at or below 100% of poverty according to HRSA’s Uniform Data System, the annual reporting system for HRSA-funded health center grantees to report a core set of information, including data on patient demographics.

6 Based on 2018 OPM Salary Table (https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2018/DCB.pdf).

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