“HIV Testing Factors Among Rural Black Men (HiTFARM)”
Attachment 1b. Survey Instrument
Form Approved
OMB No. 0920-0840
Expiration Date 01/31/2013
“HIV Testing Factors Among Rural Black Men (HiTFARM)”
Survey Instrument
Public reporting burden of this collection of information is estimated to average 45 minutes per response. 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-0840)
Date _______________ Study ID: _(__ __/__ __/__ __ __ )_ __ __
( mm / dd / yyyy ) FML
1. Age______(years)
2a. What county do you live in? (Select only one)
Columbia County
Hamilton County
Alachua County
2b. If Alachua County, which city or town? (Select only one)
Gainesville
High Springs
Alachua
LaCrosse
Hawthorne
Newberry
Jonesville
Micanopy
Orange Heights
Melrose
Fairbanks
Waldo
2c. How long have you lived in that county? (Select only one)
<1 year
1 – 3 years
3 – 5 years
> 5 years
3a. What is your current marital status? (Select only one)
Single/never married/living alone
Married
Separated/Divorced
Widowed
3b. Living alone
Living with female partner
3c. (Number of years? _________)
4. About how much money do you earn (or receive) in a typical month? (Select only one)
Less than $500
$500 - $999
$1000 - $1499
$1500 or more
5. How do you usually identify yourself to male or female friends?
As a straight guy who sleeps with women only
As a straight guy who sleeps with women & other guys
As a straight guy who sleeps with other guys only
I do not label myself, but sleep with other guys
As bisexual
As gay
As transgender
I do not discuss this with them
Other
6. What is the highest grade you completed?
<8th grade
8th grade
9th grade
10th grade
11th grade
12th grade
AA/AS degree
BS/BA degree
Graduate degree
7. Are you currently (Mark only one answer.)?
In an exclusive/monogamous sexual relationship (have sex only with partner)
In a non-exclusive sexual relationship (have sex with others outside the relationship)
Not in a sexual relationship
8. Have you ever had an HIV test? (Select only one.)
No
Yes
9. Have you ever been told by a doctor or nurse that you had any of the following (Mark all that apply.)
Syphilis
Gonorrhea (clap)
HIV (Human Immunodeficiency Virus)
Genital herpes
HPV, genital warts (human papilloma virus)
Hepatitis B
Hepatitis C
10. Has your ability to pay for healthcare changed within the past 3 months? (Select only one.)
No, my ability to pay for healthcare has stayed the same.
Yes, my ability to pay for healthcare has decreased (I have less money or higher healthcare costs, or both).
Yes, my ability to pay for healthcare has increased (I have more money, lower healthcare costs, or both).
. If yes, when were you last tested?
Within the last three month ______________ (please give the date)
Longer than three months go _____________ (please give the date)
10. If yes, where were you tested? (Select only one)
In a doctor’s office
In a clinic
In my neighborhood/community
11. If yes, how were you tested? (Select only one)
My blood was drawn
My finger was pricked
I held a swab in my cheek
My upper and lower gums were swabbed (rapid)
Directions: Thank you for participating in this important survey. Please follow the directions carefully and respond to each item which applies to you. You only need to touch the computer screen to go to the next page. Please ask one of the research staff members for help if needed. (We will use something similar to this statement.)
Study ID: (__ __/__ __/__ __ __ )_ __ __ ( mm/ dd / yyyy ) FML
HIV Testing History - Please note: DK= don’t know. NR= no response
|
Yes |
No |
DK |
NR |
1a. If YES, do you know the results of your most recent test? |
HIV+ |
HIV- |
|
|
|
|
________ Write the number |
|
|
|
|
________ Write the number |
|
|
|
|
No |
|
|
Attitudes toward HIV testing Please indicate whether you agree (A), disagree (DA), do not know (DK), or choose not to respond (NR) with each statement. (Please respond to each item, which applies to you.)
Statement |
A |
DA |
DK |
NR |
Getting tested for HIV helps people feel better |
1 |
0 |
88 |
99 |
Getting tested for HIV prevents people from getting HIV |
1 |
0 |
88 |
99 |
People in my life would leave me if I get HIV |
1 |
0 |
88 |
99 |
People who test HIV Positive should hide it from others |
1 |
0 |
88 |
99 |
I would rather not know if I have HIV |
1 |
0 |
88 |
99 |
Reasons for not getting HIV testing
Question 1: If you have declined rapid HIV testing in the past. Please tell us the reasons you declined by circling agree (A), disagree (DA), do not know (DK), or choose not to respond (NR) with each statement. Please skip this item and go to the next item if you have never declined rapid HIV testing.
Statement |
A |
DA |
DK |
NR |
I do not feel at risk. |
1 |
0 |
88 |
99 |
I am at risk but do not want to know my status. |
1 |
0 |
88 |
99 |
I am at risk but do not want to know my status immediately. |
1 |
0 |
88 |
99 |
I have had an HIV test within the last six months. |
1 |
0 |
88 |
99 |
I want to have the test but do not have time now. |
1 |
0 |
88 |
99 |
I do not feel comfortable being tested in this setting. |
1 |
0 |
88 |
99 |
I am not sure the results will be kept private. |
1 |
0 |
88 |
99 |
I do not want to have a finger-stick (blood drawn from hand). |
1 |
0 |
88 |
99 |
Question 2: Please tell us if any of the following prevented you from getting tested for HIV in the past by circling agree (A), disagree (DA), do not know (DK), or choose not to respond (NR). (Please respond to each item, which applies to you.) Please go to the next set of questions if you do not feel you have ever been prevented from getting tested for HIV then.
Statement |
A |
DA |
DK |
NR |
You were afraid to know if you are HIV-positive. |
1 |
0 |
88 |
99 |
You were ashamed to be seen at the testing site because others would treat you badly if they saw you there (stigma). |
1 |
0 |
88 |
99 |
You could not get to the Health Department during its open hours. |
1 |
0 |
88 |
99 |
You did not have the money to pay for the test. |
1 |
0 |
88 |
99 |
Your spouse/partner(s) did not allow you to get tested. |
1 |
0 |
88 |
99 |
You were worried that your spouse/partner(s) would physically abuse you if he/she found out you were positive. |
1 |
0 |
88 |
99 |
You had no reason to believe that you were infected. |
1 |
0 |
88 |
99 |
You were worried that other people would be told your results without your permission. |
1 |
0 |
88 |
99 |
There was no testing site close to where you live or work. |
1 |
0 |
88 |
99 |
You thought your spouse/partner(s) would stop having sex with you if you tested positive. |
1 |
0 |
88 |
99 |
Other people advised you not to get tested. |
1 |
0 |
88 |
99 |
You thought health care providers would treat you badly if you tested positive. |
1 |
0 |
88 |
99 |
You did not have access to good quality clinics for healthcare. |
1 |
0 |
88 |
99 |
You did not trust that the HIV test would give the correct result. |
1 |
0 |
88 |
99 |
You thought that there was no treatment for HIV so there was no point in being tested. |
1 |
0 |
88 |
99 |
You thought testing positive would force you to stop some sexual practices. |
1 |
0 |
88 |
99 |
You were worried that you would not have social support. |
1 |
0 |
88 |
99 |
Reasons for not disclosing HIV Positive status
Question 1: If you were to test positive for HIV and told others your status, do you think any of the following might happen to you? (Please respond to each item which applies to you circling agree (A), disagree (DA), do not know (DK), or choose not to respond (NR).
Statement |
A |
DA |
DK |
NR |
Break-up of your marriage or relationship |
1 |
0 |
88 |
99 |
Physical abuse by your spouse/partner(s) |
1 |
0 |
88 |
99 |
Loss of your job |
1 |
0 |
88 |
99 |
Be treated badly at work or school |
1 |
0 |
88 |
99 |
Loss of your friends |
1 |
0 |
88 |
99 |
Be disowned from or neglected by your family |
1 |
0 |
88 |
99 |
Be treated badly by health professionals |
1 |
0 |
88 |
99 |
Be treated like a social outcast by your community (village) |
1 |
0 |
88 |
99 |
Your family would not care for you if you became sick. |
1 |
0 |
88 |
99 |
Question 2: If you learned that your spouse or one of your partner(s) was HIV Positive, how would you react? (Please respond to each item, which applies to you circling agree (A), disagree (DA), do not know (DK), or choose not to respond (NR).
Statement |
A |
DA |
DK |
NR |
I would get a test immediately. |
1 |
0 |
88 |
99 |
I would kick my spouse/partner out of the home. |
1 |
0 |
88 |
99 |
I would assume that my spouse/partner was having sex with other people. |
1 |
0 |
88 |
99 |
I would be grateful that he/she had told me or I found out. |
1 |
0 |
88 |
99 |
I would try to hit or hurt my spouse/partner. |
1 |
0 |
88 |
99 |
I would use condoms always if I continued to stay with him/her. |
1 |
0 |
88 |
99 |
I would not have sex anymore with that spouse/partner. |
1 |
0 |
88 |
99 |
Reasons of HIV Testing
Question 1: Which of the following would help convince YOU to get tested for HIV? (Please respond to each item which applies to you circling agree (A), disagree (DA), do not know (DK), or choose not to respond (NR).
Statement |
A |
DA |
DK |
NR |
If you were tested together with your spouse or main partner |
1 |
0 |
88 |
99 |
If you had more trust in your doctor |
1 |
0 |
88 |
99 |
If you knew that no one would find out your test results |
1 |
0 |
88 |
99 |
If there was better counseling at the testing sites |
1 |
0 |
88 |
99 |
If your spouse/partner would support your decision to get tested |
1 |
0 |
88 |
99 |
If you knew that you could get treatment for HIV/AIDS |
1 |
0 |
88 |
99 |
If health care providers would treat you well if you were HIV Positive |
1 |
0 |
88 |
99 |
If there were better heath care facilities near you |
1 |
0 |
88 |
99 |
If you could be tested and get the test results on the same day |
1 |
0 |
88 |
99 |
If there were testing sites closer to your home or work |
1 |
0 |
88 |
99 |
If there were a National HIV Testing week when leaders in society such as politicians, clergy, celebrities and sports stars would get tested |
1 |
0 |
88 |
99 |
If your spouse/partner asked you to get tested |
1 |
0 |
88 |
99 |
Question 2: What are some reasons why YOU would get tested for HIV? (Please respond to each item which applies to you circling agree (A), disagree (DA), do not know (DK), or choose not to respond (NR).
Statement |
A |
DA |
DK |
NR |
You heard a TV or radio message about HIV testing |
1 |
0 |
88 |
99 |
You knew that treatment was available |
1 |
0 |
88 |
99 |
You knew test results would be confidential |
1 |
0 |
88 |
99 |
You heard you could take test and get results the same day |
1 |
0 |
88 |
99 |
You were encouraged by someone who had been tested |
1 |
0 |
88 |
99 |
You were worried about a previous sexual contact |
1 |
0 |
88 |
99 |
Your partner, family, or friends advised you to get tested |
1 |
0 |
88 |
99 |
You were sick |
1 |
0 |
88 |
99 |
Your doctor or nurse recommended that you get tested |
1 |
0 |
88 |
99 |
It was necessary to donate blood |
1 |
0 |
88 |
99 |
HIV knowledge
Question 1: Based on what you know about HIV/AIDS, which of the following do you think can help prevent people from becoming infected with HIV? (Please respond to each item, which applies to you circling agree (A), disagree (DA), do not know (DK), or choose not to respond (NR).
Statement |
A |
DA |
DK |
NR |
Using a condom during every sex act |
1 |
0 |
88 |
99 |
Using home remedies/folk medicine |
1 |
0 |
88 |
99 |
Being faithful to one partner who is faithful to you |
1 |
0 |
88 |
99 |
Praying |
1 |
0 |
88 |
99 |
Not having sex at all |
1 |
0 |
88 |
99 |
Question 2: Based on what you know about HIV, do you think people get HIV from any of the following? (Please respond to each item, which applies to you circling agree (A), disagree (DA), do not know (DK), or choose not to respond (NR).
Statement |
A |
DA |
DK |
NR |
Having vaginal or anal sex without a condom |
1 |
0 |
88 |
99 |
Using public toilets |
1 |
0 |
88 |
99 |
Receiving a blood transfusion |
1 |
0 |
88 |
99 |
Sharing needles with an HIV-positive person |
1 |
0 |
88 |
99 |
During childbirth from mother to baby |
1 |
0 |
88 |
99 |
During breastfeeding from mother to baby |
1 |
0 |
88 |
99 |
Shaking hands |
1 |
0 |
88 |
99 |
Kissing |
1 |
0 |
88 |
99 |
Question 3: Based on what you know about HIV/AIDS respond to each item circling yes(Y), no (N), do not know (DK), or choose not to respond (NR).
Questions |
Y |
N |
DK |
NR |
Can a person get HIV by sharing a kitchen or bathroom with someone with HIV? |
1 |
0 |
88 |
99 |
Can men give HIV to women? |
1 |
0 |
88 |
99 |
Can women give HIV to men? |
1 |
0 |
88 |
99 |
Must a person have many different partners to get HIV? |
1 |
0 |
88 |
99 |
Can you get HIV by touching someone with AIDS? |
1 |
0 |
88 |
99 |
Does washing after sex help protect against HIV? |
1 |
0 |
88 |
99 |
Can pregnant women give HIV to her baby? |
1 |
0 |
88 |
99 |
Can a person get rid of AIDS by having sex with a virgin? |
1 |
0 |
88 |
99 |
Is HIV the virus that causes AIDS? |
1 |
0 |
88 |
99 |
Is there a cure for AIDS? |
1 |
0 |
88 |
99 |
AIDS Perception
Question 1: Please indicate whether you agree (A), disagree (DA), do not know (DK), or choose not to respond (NR) with each statement. (Please respond to each item, which applies to you.)
Statement |
A |
DA |
DK |
NR |
People who have AIDS are dirty. |
1 |
0 |
88 |
99 |
People who have AIDS are cursed. |
1 |
0 |
88 |
99 |
People who have AIDS cannot be trusted. |
1 |
0 |
88 |
99 |
The church will not accept people who have AIDS. |
1 |
0 |
88 |
99 |
People who have AIDS should be ashamed. |
1 |
0 |
88 |
99 |
People who have AIDS should feel guilty. |
1 |
0 |
88 |
99 |
Most people become HIV Positive by being weak or foolish |
1 |
0 |
88 |
99 |
It is unsafe for people who have AIDS to work with children. |
1 |
0 |
88 |
99 |
People who have AIDS must expect restrictions on their freedom. |
1 |
0 |
88 |
99 |
People who have AIDS have done something wrong and deserve to be punished. |
1 |
0 |
88 |
99 |
People who have AIDS should be isolated. |
1 |
0 |
88 |
99 |
I do not want to be friends with someone who has AIDS. |
1 |
0 |
88 |
99 |
People who have AIDS should not be allowed to work. |
1 |
0 |
88 |
99 |
People who have AIDS should be put out of the church. |
1 |
0 |
88 |
99 |
People who have AIDS are different from everybody else. |
1 |
0 |
88 |
99 |
Sexual behavior
Question 1: Please indicate the number of male and female sexual partners you had sex with in the past three month. (Please respond to each item, which applies to you.)
How many men have you had sex with in the past 3 months? |
0 |
1 |
2 |
3 |
4 |
5+ |
How many women have you had sex with in the past 3 months? |
0 |
1 |
2 |
3 |
4 |
5+ |
Question 2: Please indicate the number of times you have had sex under each condition in the past 3 months.
Statement |
Number of times (past 3 months) |
|
||||||
I have had vaginal sex without condoms protection |
0 |
1-2 |
3-5 |
6-10 |
11-20 |
21-30 |
31-40 |
40+ |
I have had anal sex without condoms protection |
0 |
1-2 |
3-5 |
6-10 |
11-20 |
21-30 |
31-40 |
40+ |
I have had sex with blood present |
0 |
1-2 |
3-5 |
6-10 |
11-20 |
21-30 |
31-40 |
40+ |
Question 3: Please indicate the gender of your sex partners during the past 3 months: (Choose one)
Statement |
A |
DA |
DK |
NR |
Only female |
1 |
0 |
88 |
99 |
Mostly female |
1 |
0 |
88 |
99 |
Equally female and male |
1 |
0 |
88 |
99 |
Mostly male |
1 |
0 |
88 |
99 |
Only male |
1 |
0 |
88 |
99 |
No sex partners in past 3 months |
1 |
0 |
88 |
99 |
Question 4: Please indicate whether you agree (A), disagree (DA), do not know (DK), or choose not to respond (NR) to the following statements. (Please respond to each item, which applies to you.)
Statement |
A |
DA |
DK |
NR |
In the past 3 months I have never used a condom |
1 |
0 |
88 |
99 |
In the past 3 months I have had a condom brake or tear when I was using it |
1 |
0 |
88 |
99 |
In the past 3 months I have used vaseline with condoms |
1 |
0 |
88 |
99 |
In the past 3 months I have used oils or lotions with condoms |
1 |
0 |
88 |
99 |
In the past 3 months I have used KY Jell / KY Jelly with condoms |
1 |
0 |
88 |
99 |
In the past 3 months I have shared needles to inject (shoot-up) drugs |
1 |
0 |
88 |
99 |
In the past 3 months I have had a sex partner who I think used needles to shoot-up drugs |
1 |
0 |
88 |
99 |
In the past 3 months I have had a sexual disease (STD) such as Syphilis, Gonorrhea, or Herpes |
1 |
0 |
88 |
99 |
In the past 3 months I have had someone give me money, drugs, or a place to stay to have sex with me |
1 |
0 |
88 |
99 |
In the past 3 months I have given someone money, drugs or a place to stay to have sex with them |
1 |
0 |
88 |
99 |
In the past 3 months I have had sex while I was bleeding from my genitals |
1 |
0 |
88 |
99 |
In the past 3 months I have had sex while my partner was bleeding from the genitals |
1 |
0 |
88 |
99 |
Sexual and Drug use behavior
Question 1: Please indicate whether you agree (A), disagree (DA), do not know (DK), or choose not to respond (NR) to the following statements. (Please respond to each item, which applies to you.)
Statement |
A |
DA |
DK |
NR |
In the past 3 months I used condoms every time I had sex. |
1 |
0 |
88 |
99 |
In the past 3 months I was in a monogamous sexual relationship. |
1 |
0 |
88 |
99 |
In the past 3 months I was not in a sexual relationship (did not have sex). |
1 |
0 |
88 |
99 |
In the past 3 months I did not use IV drugs. |
1 |
0 |
88 |
99 |
In the past 3 months I did not share needles. |
1 |
0 |
88 |
99 |
In the past 3 months I did not have sex when I was high. |
1 |
0 |
88 |
99 |
In the past 3 months I did not have sex when I use drugs. |
1 |
0 |
88 |
99 |
In the past 3 months I did not have sex when I was drinking. |
1 |
0 |
88 |
99 |
Disclosure of HIV Positive test results
Question 1: If you tested positive for HIV, would you intend to tell any of the following individuals about your HIV test result? (Circle all that applies.)
Statement |
Unwilling to tell |
Willing to tell |
Main sex partner |
1 |
2 |
Casual sex partner |
1 |
2 |
Spouse |
1 |
2 |
Child |
1 |
2 |
Parents |
1 |
2 |
Brothers and sisters |
1 |
2 |
Other relatives |
1 |
2 |
Friends |
1 |
2 |
Neighbors |
1 |
2 |
People at work |
1 |
2 |
Reasons for Disclosure of HIV Positive test results
ACASI program will include a skip pattern for those who respond that they would NOT be willing to tell
spouse or sex partner(s). They will automatically skip to the end.
Question 1: Please tell us if you would tell your sexual partner if you tested positive for HIV for any of the following reasons. Please circle agree (A), disagree (DA), do not know (DK), or choose not to respond (NR) to the following statements. (Circle all that applies.)
Statement |
A |
DA |
DK |
NR |
I don’t want to carry this information all by myself. |
1 |
0 |
88 |
99 |
I will be able to get the information off my chest. |
1 |
0 |
88 |
99 |
I would release pent-up feelings by telling my sex partner. |
1 |
0 |
88 |
99 |
I would feel obligated to tell my sex partner. |
1 |
0 |
88 |
99 |
I don’t want to risk any health problems for my sex partner or me. |
1 |
0 |
88 |
99 |
I feel a sense of duty to tell my sex partner. |
1 |
0 |
88 |
99 |
I would want to prepare my sex partner for what might happen to me. |
1 |
0 |
88 |
99 |
My goal would be to teach my sex partner about the HIV. |
1 |
0 |
88 |
99 |
I want to see how my sex partner will feel about me after I tell. |
1 |
0 |
88 |
99 |
I want to find out if my sex partner will still want to be with me after I tell. |
1 |
0 |
88 |
99 |
I want to see how my sex partner will react after I tell. |
1 |
0 |
88 |
99 |
We love one another. |
1 |
0 |
88 |
99 |
We have a mutually supportive relationship. |
1 |
0 |
88 |
99 |
We have a close relationship. |
1 |
0 |
88 |
99 |
My sex partner would be of help. |
1 |
0 |
88 |
99 |
I trust my sex partner. |
1 |
0 |
88 |
99 |
My sex partner would be able to provide support. |
1 |
0 |
88 |
99 |
My sex partner would provide me with assistance. |
1 |
0 |
88 |
99 |
We have a lot in common. |
1 |
0 |
88 |
99 |
We both have similar types of experiences. |
1 |
0 |
88 |
99 |
We tend to think alike about things. |
1 |
0 |
88 |
99 |
Reasons for not disclosing HIV Positive test results
Question 1: Please tell us if any of the following reasons would prevent you from telling your sexual partner if you tested positive for HIV? Please circle agree (A), disagree (DA), do not know (DK), or choose not to respond (NR) to the following statements. (Circle all that applies.)
Statement |
A |
DA |
DK |
NR |
I don’t have to tell my sex partner if I don’t want to. |
1 |
0 |
88 |
99 |
I have a right to keep information about my diagnosis private. |
1 |
0 |
88 |
99 |
I have difficulty accepting that I am HIV Positive. |
1 |
0 |
88 |
99 |
I feel ashamed about being HIV Positive. |
1 |
0 |
88 |
99 |
I feel bad about myself. |
1 |
0 |
88 |
99 |
I just cannot figure out how to talk about the diagnosis. |
1 |
0 |
88 |
99 |
I don’t know how to put it into words. |
1 |
0 |
88 |
99 |
I am concerned that my sex partner will not understand. |
1 |
0 |
88 |
99 |
I worry that my sex partner would no longer like me. |
1 |
0 |
88 |
99 |
I am concerned about how my sex partner will feel about me after hearing. |
1 |
0 |
88 |
99 |
I do not feel my sex partner will be supportive. |
1 |
0 |
88 |
99 |
I would not want my sex partner to have to make sacrifices for me. |
1 |
0 |
88 |
99 |
I would not want to put my sex partner’s life into an uproar. |
1 |
0 |
88 |
99 |
I would not want my sex partner to worry about me. |
1 |
0 |
88 |
99 |
I would not want my sex partner to experience any pain. |
1 |
0 |
88 |
99 |
If our relationship wasn’t serious. |
1 |
0 |
88 |
99 |
If we weren’t very close to one another. |
1 |
0 |
88 |
99 |
If our relationship were pretty casual. |
1 |
0 |
88 |
99 |
Thank you for completing this questionnaire.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Lnw8 |
| File Modified | 0000-00-00 |
| File Created | 2021-02-03 |