Bright Futures for Women's Health and Wellness

OMB # Clearance Ends MM/DD/YYYY

Bright Futures for Women’s Health and Wellness Initiative

Clinical Implementation of “My Bright Future”

HEALTH CARE PROVIDER ASSESSMENT FORM

I. Provider Information

OMB No. 0915-xxxx

Expiration Date:

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The OMB control number for this project is 0915-xxxx. Public reporting burden for this collection of information is estimated to average 6 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-33, Rockville, Maryland, 20857.

1. Type of Provider (check one response)

 Physician

 Physician’s Assistant

 Nurse

 Nurse Practitioner

 Certified Nurse-Midwife

 Other (specify)

2. Your Sex (check one response)

 Male

 Female

3. How many years have you been a healthcare provider in the United States?

years

4. Overall, how old are the majority of the female patients that you see? (check one response)

Years	Under 21	21-45	46-64	65 and Older
Female Patients				

II. Information About Your Patients and Clinical Practice Regarding Physical Activity and Healthy Eating

5. Before using My Bright Future: Physical Activity and Healthy Eating materials, how much time on average did you spend discussing physical activity and healthy eating with each of your female patients?

Please place a check in the box that best reflects how much time you spent.	0 min	1–3 min	>3 min
a. Physical activity			
b. Healthy eating			

6. Before My Bright Future: Physical Activity and Healthy Eating materials were introduced in your setting, when did you discuss physical activity and healthy eating? (Check one response)

 At all clinical encounters

 At wellness visits

 At visits where my patients raised the topic

 Other (specify)

 I did not talk to my patients about physical activity and healthy eating.

7. Before My Bright Future: Physical Activity and Healthy Eating materials were introduced in your setting with which patients did you discuss physical activity and healthy eating? (Check one response)

 With all patients

 With patients where it was medically indicated

 With patients who raised the topic with me

 Other (specify)

 I did not talk to my patients about physical activity and healthy eating

8. Before My Bright Future: Physical Activity and Healthy Eating materials were introduced in your setting, with approximately what percent of your female patients…

Please circle your answer to each of the following statements.	0–24%	25–49%	50–74%	75–100%
a. Did you discuss their body mass index score / BMI percentile?				
b. Did you make healthy eating recommendations?				
c. Did you make physical activity recommendations?				
d. Did you facilitate goal setting related to physical activity and/or healthy eating?				

III. Preparation for the My Bright Future: Physical Activity and Healthy Eating Materials Implementation

9. How did you prepare to use My Bright Future: Physical Activity and Healthy Eating materials? (Check all that apply)

 I read the administrator handbook explaining how to use the My Bright Future: Physical Activity and Healthy Eating guide.

 I read the counseling tip sheets

 I reviewed the My Bright Future: Physical Activity and Healthy Eating Guide.

 I attended an orientation or training session.

 Other (specify)

 I did not do anything to prepare.

10. Thinking about your preparation prior to using My Bright Future: Physical Activity and Healthy Eating materials, please circle your answer to each of the following statements.

Did you…	No	Yes	N/A
a. Need more practice talking to adolescents about healthy eating?			
b. Need more practice talking to women about healthy eating?			
c. Need more practice talking to adolescents about physical activity?			
d. Need more practice talking to adult women about physical activity?			
e. Need more guidance on interpreting a health self-assessment?			
f. Need more information about physical activity?			
g. Need more information about healthy eating?			
h. Need referral practices/practitioners to help patients with healthy eating and/or physical activity?			
i. Need more guidance on helping adolescents set goals?			
j. Need more guidance on helping adult women set goals?			

11. What would you suggest be done differently to prepare providers in a setting like yours to use My Bright Future: Physical Activity and Healthy Eating materials more effectively? (PLEASE PRINT)

IV. Using the My Bright Future: Physical Activity and Healthy Eating Materials With Your Patients

12. Of the female patients who came for wellness visits during the evaluation period, with what percent of your female patients:

Please circle your answer to each of the following statements.	0–24%	25–49%	50–74%	75–100%
a. Did you use My Bright Future: Physical Activity and Healthy Eating materials?				
b. Did you review their healthy eating self-assessment?				
c. Did you review their physical activity self-assessment?				
d. Did you discuss their body mass index score (or BMI percentile)?				
e. Did you make healthy eating recommendations?				
f. Did you make physical activity recommendations?				
g. Did you facilitate goal setting about physical activity and/or healthy eating?				
h. Did using My Bright Future: Physical Activity and Healthy Eating materials help you talk to patients about healthy eating?				
i. Did using My Bright Future: Physical Activity and Healthy Eating materials help you talk to patients about physical activity?				

13. While using My Bright Future: Physical Activity and Healthy Eating materials, how much time on average did you spend discussing healthy eating and physical activity with each of your female patients? (please place a check in the box that best reflects how much time you spent)

Years	0 min	1–3 min	> 3 min
a. Physical activity			
b. Healthy eating			

14. What impact did using My Bright Future: Physical Activity and Healthy Eating materials have on the length and focus of a patient’s visit? (check all that apply)

 Visit length remained the same

 Visit length increased

 Visit length decreased

 I spent less time on other topics

 I spent more time on healthy eating

 I spent more time on physical activity

 Other (specify)

Reactions To Using My Bright Future: Physical Activity and Healthy Eating Materials

Please indicate your level of agreement with each of the following statements by checking your answer to each of the following statements.	Strongly Disagree	Disagree	Agree	Strongly Agree
15. Using the healthy eating portion of the tool increased my discussion of healthy eating.				
16 Using the healthy eating portion of the tool strengthened my discussion of healthy eating.				
17. Using the physical activity portion of the tool increased my discussion of physical activity.				
18. Using the physical activity portion of the tool strengthened my discussion of physical activity.				
19. The healthy eating portion of the tool covered important topics.				
20. The physical activity portion of the tool covered important topics.				
21. The healthy eating portion of the tool was easy to interpret.				
22. The physical activity portion of the tool was easy to interpret.				
23. The healthy eating portion of the tool was appropriate for my patients.				
24. The physical activity portion of the tool was appropriate for my patients.				
25. I would like to continue using the healthy eating portion of the tool after this trial period.				
26. I would like to continue using the physical activity portion of the tool after this trial period.				
27. I would recommend My Bright Future: Physical Activity and Healthy Eating materials to colleagues.				
28. Healthy eating is something that I should discuss with my patients.				
29. Physical activity is something that I should discuss with my patients.				
30. I gained new knowledge about healthy eating from using My Bright Future: Physical Activity and Healthy Eating materials.				
31. I gained new knowledge about physical activity from using My Bright Future: Physical Activity and Healthy Eating materials.				
32. It is important to me that my patients reach their healthy eating goals.				
33. It is important to me that my patients reach their physical activity goals.				
34. When I talked to my patients about healthy eating it helped them decide if they should change what they eat.				
35. When I talked to my patients about physical activity it helped them decide if they should be more active.				
36. I can make a difference in my patients’ eating behaviors.				
37. I can make a difference in my patients’ physical activity levels.				
Please indicate how important you feel each of the following is by checking your answer to each of the following statements.	Very Unimportant	Unimportant	Important	Very Important
38. Discussing healthy eating with patients as part of a wellness checkup				
39. Discussing physical activity with patients as part of a wellness checkup				
40. Raising health promotion/disease prevention topics with my patients as part of a wellness checkup				

To what extent, if at all, has using My Bright Future: Physical Activity and Healthy Eating Materials with your patients changed your views on the following? (please check one response for each statement).

	No Change	More Important/ Agree More	Less Important/ Agree Less
41. Discussing healthy eating with patients as part of a wellness checkup			
42. Discussing physical activity with patients as part of a wellness checkup discussion of healthy eating.			
43. Raising health promotion/disease prevention topics with my patients.			
44. Healthy eating is something that I should discuss with my patients.			
45. Physical activity is something that I should discuss with my patients.			
46. I can make a difference in my patients’ eating behaviors.			
47. I can make a difference in my patients’ physical activity levels.			

48. What would have made it easier to use My Bright Future: Physical Activity and Healthy Eating materials with your patients?
(check all that apply)

 Policy changes

 More organizational support

 Longer appointments/more time

 Reimbursement changes

 Patients with better reading skills

 Patients who were more interested in healthy eating

 Patients who were more interested in physical activity

 Relative importance of physical activity and healthy eating

 Other (specify)

 Nothing, it worked fine

To what extent did each of the following limit your use of My Bright Future: Physical Activity and Healthy Eating materials?	Not at All	To a Minimal Extent	To a Moderate Extent	To a Great Extent
49. The length of time the materials took to use.				
50. The materials were not clear enough.				
51. The materials were too complicated for patients.				
52. The materials were not relevant.				
53. Patients did not like talking about healthy eating.				
54. Patients did not like taking about physical activity.				
55. Patients refused to complete the self-assessment.				
56. Patients refused to set goals.				

Overall, how strongly would you agree that My Bright Future: Physical Activity and Healthy Eating materials were…	Strongly Disagree	Disagree	Agree	Strongly Agree
57. Easy for patients to use				
58. Easy for providers to use				
59. Helpful for providers when talking to patients				
60. Useful to patients				
61. Useful to providers				

62. What could be done differently in implementation or setting to make My Bright Future: Physical Activity and Healthy Eating materials work better for your patients? (please feel free to attach additional paper) (PLEASE PRINT)

THANK YOU FOR FILLING OUT THIS ASSESSMENT FORM AND FOR PARTICIPATING IN THE ASSESSMENT
OF MY BRIGHT FUTURE: PHYSICAL ACTIVITY AND HEALTHY EATING MATERIALS

Please place this assessment form in the envelope provided, seal the envelope and give it to the support staff member who gave you the assessment.
She/he will forward it, unopened, to the evaluation contractor. If you would be willing to speak to the assessment contractor about your experience, please give her (Rebecca Ledsky – Health Systems Research, Inc.) a call at 202-828-5100 or e-mail her at rledsky@hsrnet.com

2