AA STD Disparities - Demographic and Behavioral Question

African American STD Disparities Health Communication Project

#0920-0798

Attachment 4

Participant Demographic and Behavioral

Pencil and Paper Questionnaire

(Phase I Only)

Form Approved

OMB No. 0920-0798

Expiration Date: 01/31/2011

Participant Demographic and Behavioral

Pencil and Paper Questionnaire

Public reporting burden of this collection of information is estimated to average 10 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 (0920-0798).

Please answer questions as honestly as you can. You may refuse to answer any question that you are not comfortable answering.

Demographics

1. How old are you?

2. Are you…

Male [Skip to Question 4]

Female

3. Are you currently pregnant?

Yes

No

4. Do you have any children?

Yes

No

5. What is the highest grade or year of school you finished?

Less than high school

Some high school

High school graduate or GED

Some college or technical school

College graduate

Some graduate school or graduate degree

6. Which best describes your total personal income during the past year?

No income

Less than $10,000

$10,000-$19,999

$20,000-$29,999

$30,000-$49,999

$50,000 or above

7. Which of the following statements best describes your current employment?

Working full-time

Working part-time

Unemployed or laid off

Other [Specify:_______________]

8. Have you ever been in jail or prison?

Yes

No

9. Do you have a primary care doctor?

Yes

No

10. Do you have health insurance? This includes insurance you may get through an employer, purchase on your own, or get through a government program like Medicaid, Medicare, the military or Veteran’s Administration.

Yes

No

STD Testing

11. When you hear the words “Sexually Transmitted Disease” or STD, do you think of HIV?

Yes

No

 Continue to next page

For the rest of the questions on this survey that ask about STDs, please answer them thinking only about STDs other than HIV.

12. Have you ever been tested for a STD?

Yes

No (Skip  to Q16)

13. When was your last test for an STD?

Less than 6 months ago

7-11 months ago

1-2 years ago

3-5yrs ago

More than 5 yrs ago…………………………………………………………….

14. Which of the following best describes how often you get tested for STDs?

__ I have been tested at least once, but not on a regular basis

__ I test regularly or after any situation where I might have been exposed to an STD

15. Which of these are the main reasons for your last STD test? Please select one or more of the following reasons. [MARK ALL THAT APPY]

I just wanted to find out if I had an STD

I was worried that I was infected

A doctor, nurse or other health care provider recommended that I get tested

The Health Department asked me to

My sex partner asked me to

I found out my sex partner cheated

I had an STD in the past and I needed to get re-tested

I was starting a new relationship

My previous sex partner told me he/she was infected after we had sex

Other reason [SPECIFY: ____________________]

Thanks, now skip to Question 17.

16. Below is a list of reasons why some people have not been tested for STDs. Which of these are the main reasons why you have not been tested? Please MARK ALL THAT APPLY.

I have not been sexually active

I have not had unprotected sex

I am afraid to find out that I have an STD

I don’t want to think about having an STD

I don’t think I am at risk

I don’t like needles

I don’t trust the results to be kept private

I would have to wait too long for the results

I don’t know where to get tested

I trust my sex partner(s)

I would be embarrassed

It is too expensive

I don’t have any symptoms

I know that I don’t have anything

I know that my partner(s) doesn’t have an STD

Some other reason [SPECIFY: ____________________________]

17. If an organization in your community offered you free, confidential STD testing, would you choose to get tested?

Yes

No

Maybe

18. How likely do you think it would be that others would find out if you or someone you know went to get tested for an STD?

Very unlikely

Not very likely

Somewhat likely

Very likely

Knowledge, Attitudes, Beliefs about STDs/HIV

19. What concerns you about getting an STD? [check all that apply]

• Others finding out I have an STD ………………………………

• Having a fatal disease (that will kill me)

• What it will do to my body (possible health effects)

• Having it forever (not being able to cure it)

• Not being able to have children

• Not being able to have sex

• Not being able to live a normal life

• Having to tell my partner

• Being rejected by partner, family or friends

• Other

• Nothing

20. Please indicate how much you agree or disagree with each of the following statements.

STDs = Sexually Transmitted Disease	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree
STDs are not a concern for me.
There are medications available to treat most STDs.
I don’t need to worry about getting an STD because I know everything about my partner(s).
Knowing whether I have an STD helps me take responsibility for myself.
Knowing whether I have an STD helps me be a responsible lover or partner.
STDs are not a big problem in my community.
I should get tested for STDs because I may be at risk.
People need education to learn how to avoid getting STDs.
I am less likely than most people to get an STD.
STD rates are higher in the African American population than in other populations.
STDs are a big concern for the people I know.
The people I know are concerned about STDs.
People with STDs have been hanging with the wrong crowd.
People with STDs should be ashamed of themselves.
Getting an STD means a woman is dirty.
Someone with an STD is damaged goods.
If someone has an STD, others will think they are a bad person.
If someone has an STD, people will gossip.
If someone has an STD, health workers will think poorly of them.
Getting an STD means a man is dirty.
If I had an STD, I would feel embarrassed.
At the clinic, everyone would know if I was being tested for an STD.
Getting an STD means I don’t take care of myself.
Getting an STD would make me feel lonely.
Getting an STD means I have poor morals.
In relationships, men feel entitled to have sex

19. What do you personally associate with sex? [circle all that apply]

physical pleasure	emotional closeness	feeling good
feeling strong	necessary evil	feeling in control, powerful
feeling used	feeling confident	obligation
feeling desired	feeling sexy	stress relief
pain	release	other

20. Have you experienced racist attitudes, beliefs or actions in your life?

Yes

No [Skip to Question 23]

21. When you feel you’ve been treated unfairly or discriminated against because of being Black, you… [Please mark all that apply]

Find comfort in your faith/spirituality

Rely on family members to help you deal with it

Shrug it off

Speak up and challenge the person’s actions or beliefs

Talk with friends to help you deal with it

Try to educate them

Get angry

Other:_______________________

Personal Behaviors

These next few questions are about your personal behaviors, including sexual activity. Please remember that your answers are kept private and anonymous.

22. Please indicate the sex of the partners you have ever had sex with [check all that apply]:

Male

Female

Transgender

23. During the past 6 months, how many people have you had sex with?

NUMBER ________

How many of these partners were men? (Number)________

How many of these partners were women? (Number)______

24. Thinking about your partner(s) in the past 6 months, which of the following methods or strategies have you used to protect yourself from STDs? [Mark all that apply, even if you use different methods with different partners]

None

Being faithful to one partner/monogamy

Using condoms

Withdrawal

Getting tested for STDs on a regular basis

Wash genitals after sex

Urinate after sex

Only have oral sex

Talked to partner(s) to make sure they’ve been tested

Talked to partner to make sure they don’t have an STD

Look at partner to see if they have an STD

Other:________________________

25. How would you rate your risk of getting infected with an STD?

Very high

High

Average (neither high nor low)

Low

Very low

Undecided/not sure

26. Have you ever talked to a sex partner about whether you or they ever had an STD?

Yes

No

Never had the need

27. Have you ever had a discussion with a partner about getting tested for STDs?

Yes

No

Never had the need

28. Do you currently have a main sex partner—that is, a partner you would call your spouse, significant other, or life partner?

Yes

No [skip to Q34]

29. How long have you and your main partner been together? If you and your main partner have been together for less than 1 month, please enter 1 month as your answer.

Years			Months

30. From what you know about your main partner, how would you rate his or her risk of getting infected with an STD?

Very high

High

Average (neither high nor low)

Low

Very low

Undecided/not sure

Not applicable/Refuse to answer

31. Imagine your doctor told you “you have an STD.” Would you be willing to tell your main partner so that you could take steps to protect him/her?

Yes

No

Depends

34. Imagine your doctor told you “you have an STD.” Would you be willing to tell (all of) your current partner(s), even if they were not your main partner, so that you could take steps to protect him/her/them?

Yes

No

Depends

Please place your completed survey in the envelope and put the envelope into the box.

Thank you!