0920-10CM_Att3h_BL and Assessments NYBC 11[1].15.2010-clean

0920-10CM_Att3h_BL and Assessments NYBC 11[1].15.2010-clean.docx

HIV/AIDS Risk Reduction Interventions for African-American Heterosexual Men

0920-10CM_Att3h_BL and Assessments NYBC 11[1].15.2010-clean

OMB: 0920-0873

Document [docx]

Download: docx | pdf

HIV/AIDS Risk Reduction Interventions for African-American

Heterosexual Men

0920-10CM

Attachment 3h

Data Collection: Baseline/Follow-up Assessment – NYBC

Form Approved

OMB No. 0920-XXXX

Exp. Date XX/XX/20XX

HIV/AIDS Risk Reduction Interventions for African-American

Heterosexual Men: Baseline/Follow-up Assessment – NYBC

(Attachment 3h)

Public reporting burden of this collection of information is estimated to average 45 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-09XX)

Baseline/Follow-up Assessment

Welcome! Thank you for helping us with this important project. These first few questions are for practice. They will help you get comfortable using the computer and entering your answers to different types of questions. If you have questions at any time, please ask the project staff person for help. To start, please click the "Next Question" button.

BPRA1. Some questions will ask you to answer either YES or NO...For example, "Do you like movies?"

1 Yes

0 No

BPRA2. Some of the questions will ask you to pick one answer from a list of choices. Here is an example: How much do you agree or disagree with this statement? The Matrix is my favorite movie. (Choose one)

1 Strongly Disagree

2 Disagree

3 Neither Agree nor Disagree nor Agree

4 Agree

5 Strongly Agree

BPRA3. Some of the questions will ask you to enter a number. Here is an example: How many times have you been to the movie theatre in the past three months? If you have a hard time remembering, please make your best guess.

__ __ __ number of times

BPRA4. Some of the questions will ask you to pick more than one response from a list of choices...Such as, what type of movies do you like? When you are finished answering the question, click the next question button to continue. (Check all that apply)

__ Action

__ Drama

__ Comedy

__ Suspense/ mystery

BPRA5. Has this been enough practice using the computer? If it has, click the "YES" button to begin the interview. If not, click the "NO" button to do the practice questions again. Please remember to ask the project staff person for any assistance.

1 Yes

0 No

If BPRA5 is equal to 0 then Please call the project staff person to come and assist with the practice questions and skip to instruction before BPRA1.

Now we have some background questions. These questions let us know something about the people who participate in this study.

Age

BDEM1. How old are you? _________

Place of birth

BDEM2.Where were you born?

1 United States

2 Africa

3 Canada

4 Caribbean

5 Central America

6 Europe

7 South America

8 Other

[IF 1 OR 98, SKIP TO BDEM4]

BDEM3. If not born in the US, how old were you when you first came to live in the United States?

________

Race/ ethnicity

BDEM4. Do you consider yourself to be Hispanic or Latino?

1 Yes

0 No

BDEM5. How do you describe your race? You may select more than one answer.

`01 Black

02 White

03 Asian or Pacific Islander

04 American Indian or Alaskan Native

BDEM6. If BDEM5 = 1. How would you describe your ethnic background. You may select more than one answer.

01 African American

02 West Indian, Caribbean, English speaking

03 Caribbean, Spanish speaking

04 Caribbean, French or Creole speaking

05 Hispanic

06 African

97 Don't Know

Education

BDEM7. What is the highest level of education you completed? (Choose one)

1 Did not complete high school
2 Completed high school or GED equivalent
3 Completed vocational/technical/trade school
4 Some college or two year degree
5 Completed college (4 years) or higher

BDEM8. Are you currently enrolled in school? 1 1 Yes - Full time

2 Yes - Part time

0 No

Income/employment

BDEM9. What best describes your current employment status? (Choose one)

1 Working full-time

2 Working part-time (including seasonal/work-study, etc.)

3 Not working

BDEM10. What was your personal income last year from all sources before taxes? (Choose one)

01 Less than or equal to $5,000.00 per year

02 Between $5,001 and $10,000

03 Between $10,001 and $15,000

04 Between $15,001 and $20,000

05 Between $20,001 and $50,000

06 Greater than $50,001

97 Don't Know

BDEM11. How many people, including yourself, did you support with this income:

1 Myself

2 Two

3 Three

4 Four

5 Five or more

7 Don't Know

BFDEM12. Do you currently receive any form of public assistance, such as food stamps, home relief (cash benefits) or TANF (temporary assistance to needy families)?

1 Yes

0 No

BFDEM13. Do you currently receive some form of disability income, such as SSI (Supplemental Security Income) or SSD (Social Security Disability) or both?

1 SSI

2 SSD

3 Combination of SSI and SSD

4 Not sure which, but get disability

0 No

BFDEM14. In the last 3 months, how often did you NOT have enough money in the household for rent, food, or utilities (for example, gas, electric, phone)? (Choose one)

0 Never

1 Once in a while

2 Fairly often

3 Very Often

Living Situation

BFDEM15. Where are you currently living/staying most of the time? (Choose one)

01 My own apartment or house

02 My spouse/partner’s apartment or house

03 My parents’ or relatives’ apartment or house

04 A friend’s apartment/house

05 Homeless (on the street, shelter, car, etc.)

06 Rehabilitation center, clinic, jail or hospital

97 Don't Know

BFDEM16. Do you currently live with your partner/spouse, other family, friends/roommates, other people or alone? (check all that apply) (Please note: If you live with different people at different times of the week, please check who you live with most of the time)

1 Partner/spouse

2 Child/children

3 Parents/Grandparents

4 Other relatives (for example, brothers, cousins, etc.)

5 Friends/roommates

6 Other people (group housing)

7 Alone

BFDEM17. Do you have children, either biological or adopted?

1 Yes

0 No

[IF 0 OR 98, SKIP TO BJ1]

BFDEM18. IF YES, Do you currently live with any of your biological or adopted children?

1 Yes

0 No

[IF 1 OR 98, SKIP TO BJ1]

BFDEM19. IF NO, If you do not currently live with any of your biological or adopted children, do you contribute to their support with money or other forms of assistance?

1 Yes

0 No

Jail/prison

BJ1. In your lifetime, how many times have you been arrested (including involvement with PINS, a time you may have been arrested but not sentenced, sentenced and incarcerated, or spent time in state prison)? (Put zero for no times)

__ __ __

000 zero Skip to 13

BJ2a.Of these arrests, how many led to an incarceration? __ __

999 Not Applicable

BFJ3. Are you currently on probation? 1 Yes

0 No

9 Not Applicable

BFJ4. Are you currently on parole? 1 Yes

0 No

9 Not Applicable

BFJ5. In the past year/3 months, how many days have you spent incarcerated?

__ __ __ DAYS

999 Not Applicable (Days)

Healthcare

BFHC1. Do you currently have any health insurance or other medical coverage such as Medicaid, Medicare, private insurance?

1 Yes

0 No

BFHC2. Where do you usually go for medical care when you are sick? (Choose one)

1 Community / Free clinic

2 Medical doctor's office

3 Health department

4 Student health center

5 Emergency room

6 Alternative practitioner (e.g., herbalist)

7 Nowhere

8 Other

Sex behaviors (general)

Now we are going to ask you about your sexual behavior. Many of the questions will ask about things that have happened in the last 3 months (since [insert calculated date]).

BFS1. Have you had vaginal and/or anal sex with a woman in the past 3 months?

1 Yes

0 No

[IF 0 or 98 SKIP TO BFM1]

BFS2. How many women did you have vaginal and/or anal sex in the last 3 months?

__ __ __ #

BFS3. In the past 3 months, how many women were new partners, that is a woman you had vaginal and/or anal sex for the first time?

__ __ __ #

BFS4. Are you currently in a sexual relationship?

1 Yes

0 No

[IF NO, THEN SKIP TO BFS6]

BFS5. Have you had sex with any other person since you began this relationship?
1 Yes

0 No

BFS6. With how many women did you have vaginal or anal sex without a condom in the last 3 months?

__ __ __ #

BFS7. In the last 3 months, did you have vaginal and/or anal sex with a main or primary female sex partner like a wife, spouse, girlfriend or significant other?

1 Yes

0 No

[IF 0 or 98 SKIP TO BFSX1]

BFS8. Was there at least one time in the last 3 months when you didn’t use a condom during vaginal and/or anal sex with this primary female partner?

1 Yes

0 No

BFS9. Over the last 3 months, how often did you use condoms during vaginal sex with your main or primary female partner?

0 Never

1 Sometimes

2 Often

3 Always

4 did not have vaginal sex

BFS10. Over the last 3 months, how often did you use condoms during anal sex with your main or primary female partner?

0 Never

1 Sometimes

2 Often

3 Always

4. did not have anal sex

BFS11. Over the past 3 months, was there ever a time when you had vaginal and/or anal sex with your primary female partner one day, had vaginal and/or anal sex with someone else on a following day, and then had vaginal and/or anal sex with your main partner after that?

1 Yes

0 No

BFS12. Does your primary female sex partner want to become pregnant?

1 Yes

0 No

BFS13. Right now, are you living with a primary female sex partner like wife, spouse, girlfriend, or significant other?

1 Yes

0 No

BFS14. What is the HIV status of your primary female sex partner?

0 HIV negative

1 HIV positive

2 Don’t know

Sex Exchange

BFSX1. In the last 3 months, did you give a woman food, money, drugs, a place to stay or other favors in exchange for sex?

1 Yes

0 No

BFSX2. In the last 3 months, did a woman give you food, money, drugs, a place to stay or other favors in exchange for sex?

1 Yes

0 No

Sex and alcohol/ substance use

BFAOD1. In the past 3 months have you had vaginal or anal sex while you were drunk or buzzed on alcohol?

1 Yes

0 No

[IF 0 OR 98, SKIP TO BDA0D3]

BFAOD2. If yes, how often did you use condoms when you had vaginal or anal sex while you were drunk or buzzed on alcohol?

0 Never

1 Sometimes

2 Often

3 Always

BFAOD3. In the past 3 months have you had vaginal or anal sex while you were using drugs that were not prescribed by your doctor?

1 Yes

0 No

[IF 0 OR 98, SKIP TO BFM1]

BFAOD4. If yes, which drugs did you used during those times? (check all that apply)

1 Marijuana (pot, joint, spliff, ganja, weed)

2 Powdered Cocaine

3 Rock or Crack Cocaine

4 Methamphetamines, other amphetamine (Crystal Meth, Speed, Tina, Ice)

5 Poppers (Amyl Nitrate)

6 Ecstasy (E, X, MDMA)

7 Drugs like Special K, GHB (G, GBL), Rohypnol (roofies)

8 Heroin

9 Viagra or similar drugs (Levitra, Cialis)

10 Recreational use of prescription drugs (other than Viagra) to get high

11 Other drugs

BFAOD5. How often did you use condoms when you had vaginal or anal sex when you were using drugs?

0 Never

1 Sometimes

2 Often

3 Always

BFM1. In the past 3 month, have you had oral or anal sex with a man?

1 Yes

0 No

HIV testing

BHT1. Have you ever been tested for HIV?

1 Yes

0 No

[IF 0 OR 98, SKIP TO BFHT5]

BHT2. Have you been tested in the past year?

1 Yes

0 No

BFHT3. Have you been tested in the last three months?

[IF NO, SKIP TO BFHT5]

BFHT4. IF YES: What was the result of your most recent test?

1 Positive

0 Negative

7 Don’t know

[SKIP TO BFHT6]

BFHT5. What are the reasons why you have not taken an HIV test? (Check all that apply)

1 I don't have the time

2 I can't afford it

3 I don't know where to get tested

4 I am not comfortable at testing site

5 I'm afraid I might be HIV positive

6 I'm afraid that if I get tested people will think I'm gay

7 I am not at risk for HIV because I have been practicing safe sex

8 It is not important

9 My doctor never recommended I get an HIV test

10 I am afraid that if I tested positive I would lose the support of my family, friends and/or community

11 I'm afraid that if I tested positive that people might treat me differently

12 I already know/believe that I am HIV positive

13 I can't get to test site

14 Testing times are not convenient

15 I know my partners don’t have HIV

16 Other

BFHT6. Has a healthcare provider ever told you that you have HIV?

1 Yes

0 No

BFHT7. To the best of your knowledge, do you have HIV?

1 Yes

0 No

Communication –HIV status

BFCOM1. In the last 3 months before you had sex, did you talk about your HIV status (whether or not you have HIV) with every partner, some of your partners or none of your partners?

1 Every partner

2 Some of my partners

3 None of my partners

BFCOM2. In the last 3 months before you had sex, did you talk about your partner’s HIV status (whether or not your partner has HIV ) with every partner, some of your partners or none of your partners?

1 Every partner

2 Some of my partners

3 None of my partners

Condom Use Outcome Expectancies

Please tell me how strongly you agree or disagree with these statements. When we talk about your partner, we are talking about the primary or main partner you described earlier. If you do not have a main partner, please answer these questions about the partner you have sex with the most in the past 3 months.

BFCOE1. My partner would think that I have other partners if I asked to use a male or female condom.

5 Strongly agree

4 Agree

3 Neither agree/disagree

2 Disagree

1 Strongly disagree

BFCOE2. My partner would appreciate it if I asked to use protection

5 Strongly agree

4 Agree

3 Neither agree/disagree

2 Disagree

1 Strongly disagree

BFCOE3. When I want to have vaginal or anal sex with my partner, I can use a condom even if I might lose my erection or lose arousal

5 Strongly agree

4 Agree

3 Neither agree/disagree

2 Disagree

1 Strongly disagree

BFCOE4. When I want to have vaginal or anal sex with my partner, I can use a condom even if I am high on drugs or alcohol

5 Strongly agree

4 Agree

3 Neither agree/disagree

2 Disagree

1 Strongly disagree

Partner Norms for Condom Use

Again, just to remind you, when we talk about your partner, we are talking about the primary or main partner you described earlier. If you do not have a main partner, please answer these questions about the partner you have sex with the most in the past 3 months.

BFPN1. When it comes to using condoms I try to do what my partner(s) thinks is best.

1 = Strongly agree

2 = Agree

3 = Neither agree nor disagree

4 = Disagree

5 = Strongly disagree

BFPN2. My partner thinks it is important to use condoms every time for vaginal sex.

1 = Strongly agree

2 = Agree

3 = Neither agree nor disagree

4 = Disagree

5 = Strongly disagree

Condom Use Self-Efficacy

Now I want to ask you about how sure you are that you could do certain things. As I read each question, tell me which number on this card indicates how sure you are:

How sure are you that you could….

BFCSE1. Talk about using a condom with a casual partner?

1. Not sure at all

2. Somewhat sure

3. Neutral

4. Somewhat unsure

5. Very sure

BFCSE2. Buy condoms in a drug store?

1. Not sure at all

2. Somewhat sure

3. Neutral

4. Somewhat unsure

5. Very sure

BFCSE3. Refuse to have sex with someone you don't know very well?

1. Not sure at all

2. Somewhat sure

3. Neutral

4. Somewhat unsure

5. Very sure

BFCSE4. Use a condom correctly if your partner wanted to?

1. Not sure at all

2. Somewhat sure

3. Neutral

4. Somewhat unsure

5. Very sure

BFCSE5. Convince a partner that he or she should use a condom?

1. Not sure at all

2. Somewhat sure

3. Neutral

4. Somewhat unsure

5. Very sure

BFCSE6. Prevent a partner from having anal sex with you?

1. Not sure at all

2. Somewhat sure

3. Neutral

4. Somewhat unsure

5. Very sure

BFCSE7. Ask a partner about his or her other sexual partners?

1. Not sure at all

2. Somewhat sure

3. Neutral

4. Somewhat unsure

5. Very sure

Condom Attitudes

Think about how strongly you agree or disagree with the following statements.

BFCA1. Condom use can be made sexy.
(Choose one) 1 Strongly Disagree

2 Disagree

3 Neither Disagree nor Agree

4 Agree

5 Strongly Agree

BFCA2. Condoms are too much trouble to use. (Choose one) 1 Strongly Disagree

2 Disagree

3 Neither Disagree nor Agree

4 Agree

5 Strongly Agree

BFCA3. Using a condom interrupts the flow of sex. (Choose one)

1 Strongly Disagree

2 Disagree

3 Neither Disagree nor Agree

4 Agree

5 Strongly Agree

BFCA4. Using a condom turns me off. (Choose one) 1 Strongly Disagree

2 Disagree

3 Neither Disagree nor Agree

4 Agree

5 Strongly Agree

BFCA5. Condoms break too often to be safe. (Choose one) 1 Strongly Disagree

2 Disagree

3 Neither Disagree nor Agree

4 Agree

5 Strongly Agree

Condom Use PEER NORMS

BFCPN1. My friends think it is important to use condoms. (Choose one)

1 Strongly Disagree

2 Disagree

3 Neither Disagree nor Agree

4 Agree

5 Strongly Agree

BFCPN2. My friends use condoms. (Choose one) 1 Strongly Disagree

2 Disagree

3 Neither Disagree nor Agree

4 Agree

5 Strongly Agree

Perceived responsibility

The next several statements are about your opinions regarding people's responsibility for safer sex. For each item, please indicate how much you agree or disagree with the statement.

BFPR1. It's very important for me to use condoms to protect myself from HIV. (Choose one)

1 Strongly Disagree

2 Disagree

3 Neither Disagree nor Agree

4 Agree

5 Strongly Agree

BFPR2. HIV negative men have a responsibility to keep themselves from becoming positive. (Choose one)

1 Strongly Disagree

2 Disagree

3 Neither Disagree nor Agree

4 Agree

5 Strongly Agree

BFPR3. When HIV positive and HIV negative people have sex with each other, they have an equal responsibility for being safe. (Choose one)

1 Strongly Disagree

2 Disagree

3 Neither Disagree nor Agree

4 Agree

5 Strongly Agree

BFPR4. I feel responsible for protecting myself from HIV. (Choose one)

1 Strongly Disagree

2 Disagree

3 Neither Disagree nor Agree

4 Agree

5 Strongly Agree

BFPR5. It should be the responsibility of someone who is HIV positive--not someone who is negative---to make sure that sex is safe. (Choose one)

1 Strongly Disagree

2 Disagree

3 Neither Disagree nor Agree

4 Agree

5 Strongly Agree

BFPR6. I feel it is my partner's responsibility to protect me from HIV if she is positive. (Choose one)

1 Strongly Disagree

2 Disagree

3 Neither Disagree nor Agree

4 Agree

5 Strongly Agree

Sex Role:

Please state how much you agree or disagree with the following statements:

Answer choices : strongly agree, agree, neither agree nor disagree, disagree, strongly disagree

BFSR1. It is essential for a guy to get respect from others

5 Strongly agree

4 Agree

3 Neither agree/disagree

2 Disagree

1 Strongly Disagree

BFSR2. Men are always ready for sex

5 Strongly agree

4 Agree

3 Neither agree/disagree

2 Disagree

1 Strongly Disagree

BFSR3. It bothers me when a guy acts like a girl

5 Strongly agree

4 Agree

3 Neither agree/disagree

2 Disagree

1 Strongly Disagree

BFSR4. A man always deserves the respect of his wife and children

5 Strongly agree

4 Agree

3 Neither agree/disagree

2 Disagree

1 Strongly Disagree

Experience with Violence:

These next questions are about your partner, the primary or main partner you described earlier. If you do not have a main partner, please answer these questions about the partner you have sex with the most in the past 3 months.

BFV1. In your current relationship with your partner, have you ever hit, kicked, slapped, beaten or in any other way physically assaulted her?

1 Yes

0 No

BFV2. In your current relationship with your partner, have she ever hit, kicked, slapped, beaten or in any other way physically assaulted you?

1 Yes

0 No

BFV3. Are you afraid of your sex partner?

1 Yes

0 No

BFV4. Do you think that your sex partner is afraid of you?

1 Yes

0 No

Psychological distress

The next few questions are going to ask about how you have been feeling in the last month.

BFPD1. In the last month, how often did you feel tired for no good reason? (Choose one)

1 None of the time

2 A little of the time

3 Some of the time

4 Most of the time

5 All of the time

BFPD2. In the last month, how often did you feel nervous? (Choose one)

1 None of the time

2 A little of the time

3 Some of the time

4 Most of the time

5 All of the time

BFPD2. In the last month, how often did you feel so nervous that nothing could calm you down? (Choose one)

1 None of the time

2 A little of the time

3 Some of the time

4 Most of the time

5 All of the time

BFPD3. In the last month, how often did you feel hopeless? (Choose one)

1 None of the time

2 A little of the time

3 Some of the time

4 Most of the time

5 All of the time

BFPD4. In the last month, how often did you feel restless or fidgety? (Choose one)

1 None of the time

2 A little of the time

3 Some of the time

4 Most of the time

5 All of the time

BFPD5. In the last month, how often did you feel so restless that you could not sit still? (Choose one)

1 None of the time

2 A little of the time

3 Some of the time

4 Most of the time

5 All of the time

BFPD6. In the last month, how often did you feel depressed? (Choose one)

1 None of the time

2 A little of the time

3 Some of the time

4 Most of the time

5 All of the time

BFPD7. In the last month, how often did you feel everything was an effort? (Choose one)

1 None of the time

2 A little of the time

3 Some of the time

4 Most of the time

5 All of the time

BFPD8. In the last month, how often did you feel so sad that nothing could cheer you up? (Choose one)

1 None of the time

2 A little of the time

3 Some of the time

4 Most of the time

5 All of the time

BFPD9. In the last month, how often did you feel worthless? (Choose one)

1 None of the time

2 A little of the time

3 Some of the time

4 Most of the time

5 All of the time

Substance Use

BSU1. Have you ever, in your lifetime, injected illicit/illegal drugs with a needle? By this we mean drugs that have not been prescribed by your doctor.

1 Yes

0 No

[IF 0 or 98, SKIP TO BSU3 OR BFSU5]

BFSU2a. If yes, In the past three months have you injected with a needle any illicit drugs?

1 Yes

0 No

BSU3. Have you ever used any illicit/illegal drugs, not using a needle, in your lifetime?
1 Yes

0 No

[IF 0 OR 98, SKIP TO BFME1]

BSU4. If yes, which ones?

1 Marijuana (pot, joint, spliff, ganja, weed)

2 Powdered Cocaine

3 Rock or Crack Cocaine

4 Methamphetamines, other amphetamine (Crystal Meth, Speed, Tina, Ice)

5 Poppers (Amyl Nitrate)

6 Ecstasy (E, X, MDMA)

7 Drugs like Special K, GHB (G, GBL), Rohypnol (roofies)

8 Heroin

9 Viagra or similar drugs (Levitra, Cialis)

10 Recreational use of prescription drugs (other than Viagra) to get high

11 Other drugs

BFSU5. In the past three months, have you ever used any of the following drugs:

1 Marijuana (pot, joint, spliff, ganja, weed)

2 Powdered Cocaine

3 Rock or Crack Cocaine

4 Methamphetamines, other amphetamine (Crystal Meth, Speed, Tina, Ice)

5 Poppers (Amyl Nitrate)

6 Ecstasy (E, X, MDMA)

7 Drugs like Special K, GHB (G, GBL), Rohypnol (roofies)

8 Heroin

9 Viagra or similar drugs (Levitra, Cialis)

10 Recreational use of prescription drugs (other than Viagra) to get high

11 Other drugs

In this country, people come from a lot of different cultures and there are many different words to describe the different backgrounds or ethnic groups that people come from. Some examples of the names of racial and ethnic groups are Mexican-American, Hispanic, Black, African-American, White, Caucasian, etc. Every person is born into an ethnic group, and sometimes two or more groups, but people differ on how important their ethnicity is to them, how they feel about it, and how much their behavior is affected by it. These questions are about your ethnicity or your ethnic group and you feel about or react to it.

Use the numbers given below to indicate how much you agree or disagree with each statement.