ss_BPHC Patient Survey - NEW - PART A

Supporting Statement
Bureau of Primary Health Care Patient Survey
A.

Justification
1.

Circumstances Making Collection of Information Necessary

This is a request for Office of Management and Budget (OMB) approval to conduct the
Primary Health Care Patient Surveys (survey; OMB No. 0915-NEW). This is a new
information collection request. The Bureau of Primary Health Care (BPHC) within the
Health Resources and Services Administration (HRSA) for the U.S. Department of
Health and Human Service’s (DHHS) is conducting this survey. This submission
describes the procedures and instrument planned for the Primary Health Care Patient
Survey (survey).
HRSA’s Bureau of Primary Health Care administers the Health Center Program, as
authorized by Section 330 of the Public Health Service (PHS) Act, 42 U.S.C. 254b, as
amended (Attachment 1). Health centers improve the health of the Nation’s underserved
communities and vulnerable populations by assuring access to comprehensive, culturally
competent, quality primary health care services. The types of health centers authorized
under Section 330 of the PHS Act as amended are: Community Health Center (CHC)
(section 330(e)), Migrant Health Center (MHC) (section 330(g)), Health Care for the
Homeless (HCH) (section 330(h)), and Public Housing Primary Care (PH) (section
330(i)).
Health center grants provide operational support to a variety of community-based and
patient-directed public and private nonprofit organizations, which may receive grant
funding to support one or more of the four health center program types. Community
Health Center program grantees receive funding to serve a variety of underserved
populations and areas, Migrant Health Center program grantees receive funding to serve
migrant and seasonal agricultural workers and their families, Healthcare for the Homeless
program grantees receive funding to serve homeless individuals and families, and Public
Housing Primary Care program grantees receive funding to serve residents of public
housing.
The survey will include a sample of patients from all four types of section 330-funded
health center programs. Specifically, the survey will collect in-depth information about
health center patients such as their health status, the reasons they seek care at health
centers, their diagnoses, the services they utilize at health centers and elsewhere, the
quality of those services, and their satisfaction with the care they receive. This
information collection request is for approval to conduct the survey, which will consist of
a personal interview of a stratified random sample of patients of the health center
program.
The survey builds upon the successes of the Health Care for the Homeless User/Visit
Survey conducted in 2003 (OMB No. 0915-0274), the 1995 Community Health Center

User/Visit Survey (OMB No. 0915-0185), and the 2002 Community Health Center and
National Health Service Corps Site User/Visit Survey (OMB No. 0915-0186). Data
collection for the survey will be conducted in 2009 and 2010. However, the current
survey will include interviews of patients who were not targeted in the previous survey
such as migrant or seasonal farmworkers or their family members and patients who are
residents of public housing. The Research Triangle International Institutional Review
Board approved this survey; see the IRB Memo as Attachment 11.
Many of the questions on the previous patient surveys were derived from the National
Health Interview Survey (NHIS) conducted by the National Center for Health Statistics
(NCHS), allowing for comparisons between the NHIS surveys and the health center
patient surveys. The current survey instrument was developed using a similar
questionnaire methodology drawing questions primarily from the NHIS, but also from the
Medical Expenditure Panel Survey and the National Health and Nutrition Examination
Survey. Thus, comparisons will be possible between BPHC’s survey results and current
national survey data, as well as with previous patient survey data. Cognitive interviewing
was completed to identify problems with survey question wording and instructions, as
well as evaluate the timing and the flow of the questions. The cognitive interviewing
results dictated questionnaire improvements that were incorporated into the final survey
instrument (Attachment 2) submitted with this request.
The data elements included in the survey instrument aim to gather information related to
patients’: (1) care-seeking behaviors, (2) socio-demographic characteristics, (3) reasons
for seeking care, (4) health status, (5) use of services, (6) satisfaction with care, (7) unmet
health care needs, and (8) perceived quality of care. In order to meet the research goals
detailed, the following 18 modules will be administered to patients: Introduction,
conditions, access to care, routine care, follow-up conditions, cancer screening, health
center services, substance use, prescription medication, dental, mental health, prenatal
care/family planning (females aged 15-49), occupational health (all respondents aged
16+), HIV testing (all respondents aged 18+), living arrangements, health insurance,
income and assets, and demographics. Please see Attachment 3 for a table that outlines
these modules and their data elements.
The survey includes in-person interviews of patients of section 330-funded health centers.
Specifically, the survey will encompass 4,526 interviews at no more than 600 health
center sites (sites) within a sample of 115 health center grantees. Details regarding
grantee and site sampling procedures are included in Section B. Materials for
recruitment, training site staff, and data collection are included in the Attachment 4.
Specifically, introductory letters and/or materials for the grantees, sites, and patients are
included in Attachment 4 while informed consent forms and other procedural forms are
included in Attachment 5.
A BPHC Health Center grantee often has several sites. Once the grantee is recruited,
sampled health center sites will be contacted for participation in the survey. Patients seen
at the health center in the past 12 months will be eligible for selection. All interviews will
be conducted in-person by a field interviewer via Computer Assisted Personal Interview

(CAPI) in either English or Spanish at participating health center sites. (Some
rescheduled interviews may take place outside the health center. Details are included in
Section B3d.) The interviews will take approximately 1.1 hours (66 minutes). To
complete 4,526 interviews, there will be one field interviewer per sampled grantee.
Therefore, an estimated 115 local interviewers and approximately 12 traveling field
interviewers will be needed, who will supplement at sites needing additional assistance
and act as a buffer against interviewer attrition. For grantees that have a substantial
Hispanic population, a certified bilingual interviewer will be used.
Interviewers will employ one of the following informed consent procedures depending on
respondent type.
-

Self-consent for adult respondents aged 18 and older
Parental/guardian consent for child respondents aged 12 and younger (proxy
interviews) — interviewers will present the subject with a copy of the
Parent/Guardian Participation in Proxy Interview for Accompanied Children
Consent Form (with Flesch-Kincaid Reading Level at 8.0) and read it aloud.
Afterward, the subject will be invited to ask any questions about the study.
Respondents who agree to participate will be asked to sign the consent form; if
respondents cannot sign their names they will be asked to make a mark for their
names.
Parental/guardian consent and adolescent assent for respondents aged 13 to 17
who are accompanied by a parent/guardian

-

All data collection materials that are shown or read to respondents will be available in
both English and Spanish (the later of which will only be used by certified bilingual
interviewers).
2.

Purposes and Uses of the Information Collection

The survey is unique in its effort to capture person-level data from patients of all types of
Health Center Program grantees. BPHC does not routinely collect this type of
information from health center sites and these data are not available from the Uniform
Data System or any other source. With the current survey, BPHC aims to:
•
•
•

Gather data about the patients of the CHC, MHC, HCH, and PH programs and the
services they obtain;
Enable comparisons of care received by health center patients with care received
by the general population, as measured by NHIS and other national surveys; and
Gather information which will assist policymakers and BPHC staff to:
• Assess how well HRSA-supported health care sites are currently able to
meet health care needs;
• Identify areas for improvement and guide planning decisions; and
• Complement data that are not routinely collected from other BPHC data
sources.

Specifically, the BPHC priorities for analysis will be:
1. Comparison of CHC program patients with national data from the NHIS;

2. Comparisons within CHC program patients;
3. Comparisons of PH program patients with CHC program patients;
4. Comparisons of MHC program patients with HCH program patients;
5. Comparison of HCH program 2009 survey patients with HCH program 2003
survey patients; and
6. Comparison of CHC program 2009 survey patients with CHC program 2002
survey patients.

3.

Use of Improved Information Technology and Burden Reduction

The survey interview will be administered in-person with trained field staff using a
computer-assisted personal interview (CAPI) questionnaire. The use of CAPI will enable
the interview to be completed in less time and with more accuracy than conventional
paper interviewing techniques. If necessary, respondents will be able to complete a
portion of the interview and return to complete the interview at a later time, rather than
requiring the interview to be completed in a single session. In addition, random portions
of each interview will be recorded by the laptop using computer-assisted recorded
interview (CARI) technology for subsequent review by the project staff.
4.

Efforts to Identify Duplication and Use of Similar Information

The information to be collected through the Primary Health Care Patient Surveys is
unique and cannot be obtained elsewhere.
5.

Impact on Small Businesses or Other Small Entities

This project will not have a significant impact on small businesses or small entities.
6.

Consequences of Collecting the Information Less Frequently

The survey will be conducted once. Each grantee, site, and patient will only participate
in this survey once. Multiple sites within each sampled grantee may be selected to
participate and the data collection period at each site may vary depending on the number
of patients to be surveyed at that site.
7.

Consistency With Guidelines in 5 CFR 1320.5(d)(2)

This information collection fully complies with 5 CFR 1320.5(d)(2).
8.

Consultation Outside the Agency

The notice required by 5 CFR 1320.8(d) was published in the Federal Register on
December 10, 2008 (Vol. 73, No. 238) on pages 75120-75121. No comments were
received. The development of the survey included consultations with persons and
organizations both internal and external to HRSA and HHS. These individuals provided
critical review and input on the design of the survey.
A Technical Advisory Panel (TAP) was assembled and a list of the participants on the
project’s TAP is provided (Attachment 6). Membership represented a broad spectrum of
grantee staff members, representatives from coalitions/associations, nationally recognized

research experts, and the Federal government. Panel members served as expert reviewers
on the instrument design. A meeting took place in February of 2008 where the TAP
reviewed the draft questionnaire. The reviewers received input and recommendations
were incorporated into the survey and instrument design.
9.

Remuneration to Respondents

Respondents will be provided with remuneration valued at $25 for taking part in a 66minute English or Spanish interview. Consistent with the procedures used in the 2003
Health Care for the Homeless User/Visit Survey (OMB number 0915-0274), project staff
will consult with site staff to determine their preferred form of remuneration, which may
include one of the following alternatives to cash remuneration: Visa gift cards, food
vouchers, telephone cards, personal hygiene bags, and movie tickets. The non-cash
remuneration options mitigate the potential for the incentive to facilitate substance abuse,
which is particularly a concern for organizations that provide services to homeless
individuals. All patients participating at a site will receive the same form of
remuneration. Interviewers will be required to complete a receipt for all remuneration
and have the respondent sign the receipt.
10.

Assurance of Confidentiality

Participating individuals and institutions will be informed that the information provided
in the survey will be kept secure and will be protected. Data collected will be in total
conformity with HRSA’s standards for protecting personally identifiable information on
individuals. Consistent with the Privacy Act of 1974, HRSA will not provide participant
names or information about participants to persons who are not part of the survey team.
The plan for maintaining privacy is outlined in a Data Security Plan (Attachment 7).
Some highlights from the Data Security Plan include (1) procedures for safeguarding
survey materials in the field, (2) procedures for shipping and storing, and 3) the training
on data privacy and security protocols to be provided to survey staff.
To avoid someone obtaining the information provided during the interview, the interview
will be conducted in a private location where answers cannot be overheard. In addition,
an identification (ID) number will be created which will be used instead of the
respondent’s name. The patients will also be selected for the study using onsite
recruitment procedures that will protect the patients’ identity before they consent to
participate in the study. The patient selection procedures are also designed to address
HIPAA privacy concerns, as the health centers will not be asked to provide patient
names. The interviewer will not be allowed to approach any of the site’s patients nor
obtain any information about the patients unless the selected patient voluntarily initiates
contact with the interviewer. The consent form accompanying the questionnaire will
serve to inform respondents that their participation is voluntary and will reiterate the
protection of survey information.
All of the information collected will be kept private. Project staff will keep in their
possession the forms for recording respondent consent, receipt of remuneration, and the
actions which took place with each case including the current case status (via a contact
summary report form). The data collection protocol was designed to minimize the
amount of identifying information (i.e., information which could identify the respondent

as a participant in the study) that is stored on paper forms. Only the consent form and the
contact summary report form will include the respondent’s personal information. The
consent form will include the respondent’s signature while the contact summary report
form will include the respondent’s case id and only if an appointment is set the
respondent’s first name, contact number, appointment location, and parent or guardian’s
name (if applicable).
11.

Questions of a Sensitive Nature

The survey instrument contains several items, which may be viewed as “sensitive.”
The following is the additional justification for those areas that have been identified as
potentially sensitive:
1. Questions on substance use and mental health status, and perceived need for and
use of mental health and substance abuse services may be perceived as sensitive
by some respondents. However, such information is important for understanding
of the degree of unmet need for mental health and substance abuse services.
2. Questions on HIV testing status and HIV infection status may be perceived as
sensitive by some respondents. However, such information is important for
understanding the HIV testing and/or treatment experiences of health center
patients.
3. There are questions inquiring about the respondent’s family income and receipt of
public assistance. The question is designed to obtain the most accurate response to
annual income. However, respondents can elect to respond using an income range
if they feel more comfortable.
As noted in the informed consent procedures detailed previously, prior to conducting the
interview all respondents are informed about the voluntary nature of their participation
and the private treatment of their survey responses.
12.

Estimates of Annualized Burden Hours and Costs

Burden estimates for data collection activities and estimated costs to respondents are
presented in Table 1.

Table 1. Maximum estimated costs to respondents for the survey
Survey
Type of
Respondent;
Number of
Respondents

Responses
per
Respondent

Total
Number of
Responses

Burden per
Respondent

115

3

345

3.75

Patient
Recruitment

5658

1

5658

Patient
Survey

4526

1

4526

Total –
Survey

5,773

Activity
Involved

Total
Burden
Hours

Rate per
hour ($)

Total Cost
($)

1294

10

12940

.167

945

10

9450

1.10

4979

10

49790

Grantee/Site
Recruitment
and Site
Training

10,529

7218

$72180

13. Estimates Other Total Annual Cost Burden to Respondents and Record
Keepers
There are no capital, startup, or operating costs to respondents for participation in the
project. No equipment, printing, or postage charges will be incurred to respondents.
14.

Estimated Cost to the Federal Government

The estimated cost to the Federal Government includes contract costs and the costs for
the Project Officer monitoring the activity. The costs are categorized by contract costs
total costs in Table 2.
Included in the contract estimates are all staff time, reproduction, postage and telephone
costs associated with the management, data collection, analysis, and reporting.
Table 2. Individual and total costs to HRSA
Costs
HRSA Salaries and expenses
Contract costs
Total

15. Changes in Burden
This is a new data collection activity.

Amount (in $)
45,600
3,798,121
3,843,721

16.

Time Schedule, Publication and Analysis Plan

The operational schedule for the survey is shown in Table 3. This will not be a public
use data file. The results of the survey will be used in internal and external presentations
regarding the Health Center Program, and for analyses, including analyses that may be
published in peer-reviewed journals. In addition, conducting the patient survey is one of
the items on BPHC’s Program Assessment Rating Tool (PART) Improvement Plan.
Table 3. Operational schedule for survey
Projected Completion
(# weeks post OMB Approval)

Activity
Recruit Grantees and Sites

Week 19

Interviewer Training

Week 20

Data Collection

Week 37

Final Report and Products Delivery

Week 46

17.

Exemption for Display of Expiration Date

The expiration date for OMB approval of the information collection will be displayed on
data collection instruments and materials. No special exception to this request is
requested.
18.

Exceptions to Certification for Paperwork Reduction Act Submissions

There are no exceptions to the certification statement.