Form 0920-18AWP General Population Survey

Form Approved

OMB No. 0000-0000

Exp. Date 00/00/201X

Attachment 3a:

General Population Survey

Public reporting burden of this collection of information is estimated to average 28 minutes per response, 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

WINTRO_1 Thank you for agreeing to participate in our study!

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Continue from where I left off

Now we would like to ask some general questions about your health and lifestyle.

GENHEALTHSTATGP. In general would you say your health is…

Excellent

Very good

Good

Fair

Poor

Prefer not to answer

We know that people have very different experiences with access to and satisfaction with the kind of medical care they have received. We would like to ask you a few questions about your experiences.

DOCTORVISIT. About how long has it been since you last saw or talked to a doctor or other health care professional about your own health?

Never

6 months or less

More than 6 months, but not more than 1 year ago

More than 1 year, but not more than 2 years ago

More than 2 years, but not more than 5 years ago

More than 5 years ago

Don’t know

Prefer not to answer

PRIPLACEHADVGP. Is there a place that you usually go to when you need routine or preventive care, such as a physical examination or check-up?

Yes

No

Prefer not to answer

PRIPLACEHADVB. [if have a place usually go for care] What kind of place do you usually go to when you need routine or preventive care, such as a physical examination or check-up?

Clinic or health center

Doctor’s office or HMO

Hospital emergency room

Hospital outpatient department

Urgent care clinic

Some other place

Don’t know

Prefer not to answer

We would like to ask you some specific questions about your experiences with breast cancer screening.

MAMMOGRAMHADGP. Have you ever had a mammogram? A mammogram is an x-ray taken only of the breast by a machine that presses against the breast.

Yes

No

Don’t know

Prefer not to answer

NUMMAMMO. [if yes to mammogram] How many mammograms have you had in the last 6 years?

_________ (report number 0 – 95)

Don’t know

Prefer not to answer

MAMMOGRAMDATE. [if yes to mammogram] When did you have your MOST RECENT mammogram?

A year ago or less

More than 1 year, but not more than 2 years

More than 2 years, but not more than 3 years

More than 3 years, but not more than 5 years

Over 5 years ago

Don’t know

Prefer not to answer

Did you have a mammogram in any of the following years? (provide an answer for each year using radio buttons)

	Yes	No	Not sure/Don’t remember
2019
2018
2017
2016
2015
2014

[if female and 40 or older]

REASONMAMMO. [if yes to mammogram] What was the MAIN reason you had your most recent mammogram?

It was time to get another mammogram

You were having a problem with your breasts

Doctor or nurse told you should have one done

Other, please specify:

Thinking back over your experiences having or trying to have a mammogram, how satisfied or dissatisfied have you been with each of the following:

	Very Satisfied	Satisfied	Neither Satisfied or Dissatisfied	Dissatisfied	Very Dissatisfied	N/A
Your ability to get an appointment at a time that was convenient for you?
How long you had to wait to have the mammogram after you made the appointment?
How long you had to wait at the place you had a mammogram after you arrived for your appointment?
How far you had to travel from home or work to the place you had your mammogram?
The availability of parking where you got the mammogram?
The ability of people who work where you had your mammogram to speak a language you could understand?
The way you were treated by the people who work at the place where you had the mammogram?
The way the people who work where you had the mammogram took into account any health problems or disabilities you might have?
The cost of the mammogram?

Do you have to take time off from work or volunteer activities to get a mammogram?

Yes

No

Don’t know

Do you have to take time off from caring for children, grandchildren, or other family members in order to get a mammogram?

Yes

No

Don’t know

How uncomfortable is it to have a mammogram?

Not at all uncomfortable

Slightly uncomfortable

Moderately uncomfortable

Very uncomfortable

How painful is it to have a mammogram?

Not at all painful

Slightly painful

Moderately painful

Very painful

How embarrassing is it to have a mammogram?

Not at all embarrassing

Slightly embarrassing

Moderately embarrassing

Very embarrassing

How nervous or anxious are you when you’re getting a mammogram?

Not at all nervous

Slightly nervous

Moderately nervous

Very nervous

Have you ever had a mammogram before that showed any problems, where follow-up tests or procedures were recommended?

Yes

No

Have any of your female family members ever had breast cancer? This includes your mother, sisters, daughters, aunts, and grandmothers.

Yes

No

Don’t know

If yes, how many women in your family have had breast cancers?

Report number [1-99]:

How often do you think women your age should have mammograms?

Once a year

Once every two years

Once every three years

Every four years or more

Whenever the doctor tells you to

Whenever there are problems

DK

At what age do you think women should start having mammograms?

In their 30s

In their 40s

In their 50s

DK

How much do you agree with each of the following statements?

	Strongly Agree	Agree	Neither Agree nor Disagree	Disagree	Strongly Disagree
A mammogram can detect cancer in your breast at an early stage when it is easier to treat
A mammogram could miss cancer that you might have
Mammograms may cause you to have breast problems because of pressure from the machine
You should have mammograms even if breast cancer doesn’t run in your family
You should not have a mammogram unless you have breast problems or symptoms
If you have one mammogram in your lifetime, that is enough

Have you ever had a mammogram from a mobile mammogram van or at a place that wasn’t a traditional mammography center?

Yes

No

If yes: Did you receive the mammogram from a mobile van or other location?

Mobile van

Other, please specify:

Overall, how would you rate your experience(s) getting a mammogram from a mobile van or alternative site?

Very good

Good

Not good, but not bad

Bad

Very bad

Did you trust the results of the mammogram just as much as if the mammogram had been at a traditional location?

Yes

No

Would you get a mammogram from a mobile van or alternative site again?

Yes

No

Have you ever received a reminder, like a letter or postcard in the mail, or a phone call, to remind you to have a mammogram?

Yes

No

Don’t know

Have you ever received educational pamphlets or brochures about breast cancer screening and mammography?

Yes

No

Don’t Know

Have you ever received one-on-one educational information about breast cancer screening and mammography?

Yes

No

Don’t know

Have you ever received educational information in a group setting about breast cancer screening and mammography?

Yes

No

Don’t know

Have you ever seen posters or television commercials (or heard radio commercials) about getting a mammogram?

Yes

No

Don’t Know

Have you ever received a voucher or other reimbursement to reduce the out-of-pocket costs of getting a mammogram?

Yes

No

Don’t know

Have you ever received a mammogram through a screening program that provides mammograms for little to not cost?

Yes

No

Don’t know

Have you ever had a mammogram at a place that offered any of the following options?

	Yes	No	DK
Alternative hours, like open on weekends or late into the evening
Provided transportation to and from mammogram
Provided assistance with child care or other dependent care
Provided language translation services

Have you ever wanted or needed to get a mammogram but were not able?

Yes

No

Overall, how challenging is it for you to get a mammogram?

Very challenging

Somewhat challenging

A little challenging

Not at all challenging

Next, we are going to ask you some questions about your perceptions and understandings of breast cancer.

Several things have been shown to cause breast cancer. One a scale of one to 5, with 5 meaning that it plays a very large role in causing breast cancer and 1 meaning it does not play a role in causing breast cancer, how much of a role do you think each of the following play in causing breast cancer?

	Plays a very large role in causing breast cancer (5)	(4)	(3)	(2)	Does not play a role in causing breast cancer (1)	Don’t Know
Environmental factors (e.g. pollution, chemicals, or pesticides)
Lifestyle or behavioral factors (e.g. not exercising, tanning, drinking alcohol, or smoking)
Stress or trauma (e.g. difficult life events)
Genetics (e.g. cancer runs in the family)
Biological factors (e.g. age, menopausal status, or having children)
Pre-existing diseases (e.g. infections or other chronic conditions)
Emotions (e.g. depression or being a pessimist)
Chance or bad luck
Karma or God’s will

Are there any additional things, not already mentioned above, that you think could play a role in causing breast cancer in women?

{free text response}

For each of the following, please indicate if you believe this would generally increase, have no effect on, or decrease a woman’s chances of developing breast cancer

Exercising for 30 to 60 minutes most days of the week	Increase	No Effect	Decrease	Don’t Know
Eating a low-fat diet	Increase	No Effect	Decrease	Don’t Know
Eating more servings of fruits and vegetables per day	Increase	No Effect	Decrease	Don’t Know
Gaining weight after menopause	Increase	No Effect	Decrease	Don’t Know
Drinking one glass of red wine per day	Increase	No Effect	Decrease	Don’t Know
Drinking more than one alcoholic beverage per day	Increase	No Effect	Decrease	Don’t Know
Being exposed to chemicals or toxins in the environment	Increase	No Effect	Decrease	Don’t Know
Using hormone replacement therapy after menopause	Increase	No Effect	Decrease	Don’t Know
Using oral contraceptives (birth control)	Increase	No Effect	Decrease	Don’t Know
A blow or other injury to the breast	Increase	No Effect	Decrease	Don’t Know
A stressful life	Increase	No Effect	Decrease	Don’t Know
A family history of breast cancer on my mother’s side of the family	Increase	No Effect	Decrease	Don’t Know
A family history of breast cancer on my father’s side of the family	Increase	No Effect	Decrease	Don’t Know
Breastfeeding	Increase	No Effect	Decrease	Don’t Know
Having your first period at a young age	Increase	No Effect	Decrease	Don’t Know
Not having children	Increase	No Effect	Decrease	Don’t Know
Breast implants	Increase	No Effect	Decrease	Don’t Know
Antiperspirants	Increase	No Effect	Decrease	Don’t Know

[all respondents]

CANCERLIKELY. How likely are you to get breast cancer in your lifetime?

Very likely

Likely

Neither likely or unlikely

Unlikely

Very unlikely

Don’t Know

CANCERWORRY. How worried are you about getting breast cancer?

Extremely

Moderately

Somewhat

Slightly

Not at all

Don’t Know

The items listed below refer to your health. Please read each item carefully and indicate to what extent you agree with each:

	Not agree at all	Slightly agree	Somewhat agree	Moderately agree	Very much agree
I expect that my health will be excellent in the future.
I believe that the future status of my physical health will be positive.
I do not expect to suffer health problems in the future.
I anticipate that my physical health will deteriorate in the future.

How much do you agree or disagree with each of the following statements?

	Strongly Agree	Somewhat agree	Somewhat disagree	Strongly disagree	Prefer not to answer
CAUSECANCER. It seems like everything causes cancer
LOWERCANRISK. There’s not much you can do to lower your chances of getting cancer
RECOMCONFUS. There are so many different recommendations about preventing cancer, it’s hard to know which ones to follow
PREFOBLIV. I’d rather not know my chances of getting cancer

SEEKCANRINFOGP. Have you ever looked for information about cancer from any source?

Yes

No

Prefer not to answer

INFOSEEKGP. [if ever looked for information] The most recent time you looked for information about cancer, where did you go first?

Internet

Book

Brochures or pamphlets

Cancer organization

Family, friend, or co-worker

Doctor or health care provider

Library

Magazine or newspaper

Telephone information number

Complementary or alternative practitioner

Prefer not to answer

PERSONINFO. [if ever looked for information] The most recent time you looked for information about cancer, who was it for?

Myself

Someone else

Both myself and someone else

Prefer not to answer

[if ever looked for information] Based on the results of your most recent search for information about cancer, how much do you agree or disagree with each of the following statements?

	Strongly Agree	Somewhat Agree	Somewhat Disagree	Strongly Disagree	Prefer not to answer
CNRLVLOEFFRTGP. It took a lot of effort to get the information you needed
CNRFRSTRATEDGP. I felt frustrated during your search for information
CNRCONCRQUALGP. I was concerned about the quality of the information
CNRHARDTOUNDGP. The information you found was hard to understand

CONFIDENTINFO. Overall, how confident are you that you could get advice or information about cancer if you needed it?

Completely confident

Very confident

Somewhat confident

A little confident

Not at all confident

Prefer not to answer

To help us develop better health information, please answer the following questions about your preferences.

When reading the newspaper, how helpful do you find tables and graphs that are parts of the story?

Not at all helpful					Extremely Helpful
1	2	3	4	5	6

When people tell you the chance of something happening, do you prefer that they use words (“it rarely happens”) or numbers (“there is a 1% chance”)?

Always prefer words					Always prefer numbers
1	2	3	4	5	6

When you hear a weather forecast, do you prefer predictions using percentages (e.g. “there will be a 20% change of rain today”) or predictions using only words (e.g. “there is a small chance of rain today”)?

Always prefer percentages					Always prefer words
1	2	3	4	5	6

How often do you find numerical information to be useful?

Never					Very Often
1	2	3	4	5	6

Finally, we have a few questions solely for statistical purposes.

These next questions are about health insurance. Please include health insurance obtained through employment or purchased directly. Also include government programs, like Medicare and Medicaid.

INSURTYPEGP. What kind of health insurance or health care coverage do you have? (Select all that apply)

Exclude private plans that only provide extra cash while hospitalized.

Private health insurance, including those obtained through a state or federal exchange or healthcare.gov, or through the Affordable Care Act, also known as Obamacare

Medicare

Medi-Gap

Medicaid

SCHIP

Military health care (TRICARE/VA/CHAMP-VA)

Indian Health Service

State-sponsored health plan

Other government program

Single service plan (e.g. dental, vision, prescription)

No coverage of any type

Prefer not to answer

INSURSOURCEGP. [if have private insurance] Which one of these categories best describes how your private insurance plan was obtained?

Through employer

Through union

Through workplace (don’t know if union or employer)

Through workplace – self-employed or professional association

Purchased directly

Through Healthcare.gov or the Affordable Care Act, also known as Obamacare

Through a state/local government or community program

Other

Don’t know

Prefer not to answer

INSURYEAR. In the past 12 months, was there any time when you did not have any health insurance coverage?

Yes

No

Don’t know

Prefer not to answer

EDUCATIONGP. What is the highest grade or level of schooling you completed?

Grade 11 or less

Completed high school

Post high school training other than college (vocational or technical)

Some college

College graduate

Postgraduate

Prefer not to answer

MARITALSTATGP. What is your marital status?

Married

Living as married

Divorced

Widowed

Separated

Single, never been married

Prefer not to answer

HISPLATINOSPAN. Are you of Hispanic, Latino/a, or Spanish origin?

Yes

No

Prefer not to answer

HISPLATGROUPGP. [if Hispanic or Latino] Which group are you from?

Mexican, Mexican American, Chicano/a

Puerto Rican

Cuban

Dominican

Central or South American

Other Hispanic, Latino/a, or Spanish origin

Prefer not to answer

RACETHNICITYGP. What is your race? You may select multiple categories.

White

Black or African American

Asian

Native Hawaiian or Pacific Islander

American Indian or Alaska Native

Prefer not to answer

OCCUPSTATUSGP. What is your current occupational status?

Employed

Unemployed

Homemaker

Student

Retired

Disabled

Other {please specify: _______)

Prefer not to answer

HHINCOMEGP. Thinking about all the members of your family living in your household, what is your combined annual income, meaning the total pre-tax income from all sources earned in the past year?

Less than $20,000

$20,000 to $49,999

$50,000 to $99,999

$100,000 to $199,999

$200,000 or more

Don’t know

Prefer not to answer

INCENTX

Congratulations, in appreciation for your time and effort completing the survey, we want to send you a $5 Amazon gift card! Please enter your mailing address below so that we can send you the code.

Address

CLOSING SCREEN

This is the end of the survey.

Thank you very much for your time and effort.

If you would like more information about genetic testing for cancer risk, please visit the following resources:

Centers for Disease Control and Prevention https://www.cdc.gov/cancer/dcpc/prevention/

National Cancer Institute: https://www.cancer.gov/types/breast

If you would like more information about the study, please call 1-312-201-4412 or send an email to [email protected]. If you have questions about your rights as a survey participant, you may call the NORC Institutional Review Board Administrator (toll-free) at 1-866-309-0542.