Discussion of new questions

Attachment 4. Discussion of Consistency Between Current and New Questions

June 2011

Summary

The NSFG has had two major changes in direction and content in its 40-year history (since the program was established in 1971). The first major change was in 1982, when we added unmarried women to the sample, and expanded questions on use of family planning and reproductive health services. The second major change was in 2002, when we added men to the sample, and asked men about father involvement with their children, and both men and women about behaviors that increase the risk of sexually transmitted diseases and HIV.

On several occasions OMB has approved minor changes, and the changes between 2006-10 and 2011 are minor changes: we have added questions to the NSFG that are directly related to the questions we were already asking. In each case OMB asked about, we show that we were already asking questions that are directly related to the new questions we are proposing to add. The new questions are, then, natural extensions of what we were asking. We are now asking primarily for further details that make what we already collect much more useful.

Specific Topics

Breast cancer screening. (page 2; females)

The questions build on the contraceptive, marital, and pregnancy histories in the NSFG. The data on breast cancer screening are closely related to all the other data in the NSFG female questionnaire on use of reproductive health services and other reproductive health conditions.

There are other data (from the National Health Interview Survey, for example) on mammography among women 40 and older. But CDC’s Division of Cancer Prevention and Control (DCPC) specifically requested data from the NSFG to produce national estimates of mammography among women under 40, cross-tabulated by other variables that are not available in other surveys--on age at first intercourse, age at first birth, number of births, and use of the birth control pill and other methods of contraception, numbers of sexual partners, sexually transmitted disease (STD) history, infertility, and use of health services for contraception, infertility, and prenatal care.

Use of alcohol (females)

In the 2002 and the 2006-2010 NSFG surveys, we had already asked about use of alcohol in the last 12 months, and about binge drinking in the last 12 months. We were already asking about alcohol use in ACASI. This series of questions, for women only, asks whether the respondent has had alcohol in the last 30 days, so that it can be used to derive an estimate of the number of women at risk of an alcohol-exposed pregnancy. Thus, the topic was already being asked about, but the time frame and frequency needed to be asked in a different way in order to estimate the size and characteristics of this population, for CDC’s Division of Birth Defects and Developmental Disabilities.

Items on sex education on how to use a condom, where to obtain birth control, and waiting to have sex until marriage. (CF-8, 11, 20)

We have had a series of “sex education” items since 1995, which researchers and HHS agencies have used to shed light on issues related to sex education and teen pregnancy. For example, in the 2002 NSFG, we asked respondents “Before you were 18, did you ever talk with a parent or guardian about…” (1) How to say no to sex, (2) Methods of birth control, and (3) “How to use a condom”. In 2006-10, we added a question on whether they had talked to their parents about “how to prevent HIV or AIDS.”

In addition we have always asked about any formal instruction at school, church, or a community center or some other place before age 18 on: “how to say no to sex,” and “methods of birth control.”

In 2006-10, we added two additional topics to the questions on formal sex education in schools to make them more comparable to the questions on talking with their parents about sex education topics: “Sexually transmitted diseases,” and “How to prevent HIV/AIDS.”

This time (2011), we are simply adding 2 topics that are particularly relevant today, based on advice from experts recommended by our funding agencies. These additions also mean that we ask about the same topics in the “talking with parents” questions and in the “formal instruction” series. The 2 additional topics are:

-formal instruction on where to get birth control

-Formal instruction on how to use a condom

These questions keep the 2 series on “talking with parents” and “formal instruction” more uniform, and more up to date, but they are not opening up any new areas of questioning.

We have had sex education questions for a long time on the NSFG, and these changes are incremental.

The age at the first same-sex experience (JG-4)

This question occurs in ACASI, the self-administered part of the interview. We already (since 2002, or 34,000 interviews) had questions on whether respondents had ever had a same-sex experience, and whether they had had one in the last 12 months.

This question was added at the direct request of the CDC Division of STD to determine the age at which the person was first exposed to the risk of sexually transmitted diseases as a result of same-sex activity. The question is directly analogous to the question on age at first heterosexual intercourse, which is asked in the interviewer-administered part of the questionnaire. Note that it will be asked only for the 5-6% of men and 10% of women who have already reported (to the computer) that they have had a same-sex experience. So this item is a refinement of the questions on whether they have ever had, and recently had, a same-sex experience that increases their usefulness substantially.

Factors affecting contraceptive choice (Section E)

Contraceptive use and the choice of contraceptive methods is a central focus of the whole NSFG questionnaire (and a central concern of our funding agencies). Contraceptive use and choice is the largest determinant of US birth and pregnancy rates. We already have extensive data on contraceptive methods ever used, and currently used—about 15-20 minutes of the NSFG female questionnaire is devoted to contraceptive use!

But we had nothing that asked respondents directly what they look for in a contraceptive method, to try to explain contraceptive choice. The NSFG is a unique place to ask these questions because we have such extensive, nationally representative data on contraceptive behavior.

Pap Tests, Pelvic Exams, HPV testing, and cancer experience and attitudes.

Since 1982, we have collected an extensive set of questions on use of health care for contraception, infertility, prenatal care. We ask about 14 specific services, including receiving a birth control method, counseling or information about birth control, emergency contraception, a pregnancy test, a pap test, a pelvic exam, and testing or treatment for sexually transmitted diseases, in the last 12 months. Since 2006 we have also asked about HPV (Human Papillomavirus) tests, at the request of CDC’s Division of Sexually Transmitted Disease Prevention. (DSTDP). The new questions just ask for 3 or 4 additional facts for Pap tests, Pelvic exams, and HPV tests—such as her age when she first had the test, date of last test if more than 12 months ago, whether it was part of a routine exam or because of a specific medical concern, and how often should a woman have these test. The additional information makes the data we are already collecting much more useful to the Division of Cancer Prevention and Control of the CDC, to see if new guidelines are being followed.

Males only: Questions on father involvement

We asked an extensive set of questions on fathers’ involvement in their children’s lives in both 2002 and in 2006-2010. We ask questions about his children age 18 and younger who live with him and those who do not live with him. For younger children (under 5), these questions included how often he ate dinner with them, played with them, read to them, bathed them, etc. For older children (5-18), it included helping them with homework, taking them places, etc. The literature on fatherhood identifies several important aspects of fathering, including: responsibility, engagement, accessibility, discipline, and attachment. Several experts in this field reviewed our questions on fatherhood and suggested that we revise them to include other aspects of fathering beyond just responsibility. After researching this topic and consulting with our funders, we have made technical improvements to these questions to ask about a couple of additional aspects of father involvement. Again, these questions are refinements that increase the usefulness of the information, but they do not open up new areas of questioning.

For men who have sex with men, their recent sexual behavior and medical screening for sexually transmitted diseases.

The majority of the NSFG questionnaire is directed primarily toward heterosexual behavior, and that is appropriate since the original and still primary objective of the survey is to measure factors related to birth and pregnancy rates. However, since we began interviewing men in 2002 and 2006-10, we have conducted about 15,000 interviews with men. These interviews have included a self-administered (ACASI) portion of the male questionnaire. The respondent answers questions (by entering answers into a laptop computer) on sexual attraction, sexual identity (heterosexual or straight; homosexual or gay; bisexual), and various aspects of sexual behavior, including male-male oral and anal sex, both voluntary and non-voluntary. In these interviews, we have found that 5-6% of men have ever had sex with another man, and about half of those (2-3%) have had sex with a man in the last 12 months. It is only for this small group that some questions have been added on condom use during male-male sex, age differences between male partners, race differences (because STD’s and HIV vary so much by race/ethnicity), how the man met his male partners, and whether a doctor has asked him about his sexual behavior and condom use. We believe these are straightforward extensions of what we are already asking—extensions that greatly improve the usefulness of the data for programs trying to work with such men to control the spread of disease.

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