Community Member

Multi-site Evaluation of the In Community Spirit Program

Women’s HIV Education, Awareness, and Lifestyle (HEAL) Survey—Prevention Education

You are being asked to participate in this survey because of your participation in an HIV prevention education curriculum. American Indian women experience high rates of HIV exposure and transmission. By completing this survey openly, the information you give will be used to make HIV prevention activities more effective and helpful for American Indian and Alaska Native women.

This is not a test. Please answer the questions based on what you really think and do. Your honest answers will help us, your community, and HIV prevention service providers serving your community. DO NOT write your name on this survey. The answers you give will be kept private. No one will know what you write.

Completing this survey is voluntary. If you are not comfortable answering a question, just leave it blank.

The questions that ask about your background will be used only to describe the types of community members completing this survey. The information will not be used to find out your name. No names will ever be reported.

Please read every question and fill in the circles completely.

Contact information: If you have any concerns about your participation in this survey or have any questions about the evaluation, please contact Robin Davis at [email protected] or you may call her at 404-592-2188.

Thank you very much for your help.

OMB No. XXXX-XXXX

Expiration Date: Month Year

Public Burden Statement: 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.  The OMB control number for this project is XXXX-XXXX.  Public reporting burden for this collection of information is estimated to average 15 minutes per client per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to OWH Reports Clearance Officer, Address, City, State, Zip.

Directions:

• Complete survey with a pencil

• Make dark marks

• F ill in a response like this: Yes

N o

This section asks about your access to and knowledge of HIV testing services.

1. Is there a place where you USUALLY go when you are sick or need advice about your health?

¡ Yes

¡ No

¡ More than one place

¡ I don’t know

2. Where do you usually go for health care?

¡ I do not have a usual place

¡ Private doctor’s office

¡ School based health care center

¡ Community or tribal health clinic or center

¡ Indian Health Services facility

¡ Hospital or emergency room

¡ Traditional healer in my community

¡ Somewhere else (Please specify) _________________

3. Have you visited any of the following medical providers in the last 12 months for women’s health services? (Check all that apply.)

¡ Primary care physician or doctor

¡ Obstetrician/Gynecologist

¡ Nurse

¡ Midwife

¡ Traditional healer

¡ Community health representative

¡ Other (please specify) _______________________________________

¡ I did not visit a medical provider in the last 12 months for women’s health services.

4. Have you ever been tested for HIV (the virus that causes AIDS)?

¡ Yes àCONTINUE TO QUESTION 5

¡ No àSKIP TO QUESTION 7

¡ I don’t knowàSKIP TO QUESTION 7

5. Did you get the results of your HIV test?

¡ Yes

¡ No

¡ I don’t know

6. When was the last time you got tested for HIV?

¡ Within the last 3 months

¡ 3-6 months ago

¡ 6 months to a year ago

¡ Longer than a year ago

¡ I don’t know

¡ I don’t remember

à SKIP TO QUESTION 8

7. You marked that you have NOT been tested for HIV. There are many reasons why people might not get tested for HIV. For each of these reasons, please mark its importance for you.

	Very important reason	Somewhat important reason	Not too important	Not a reason at all
You think it is too expensive.	¡	¡	¡	¡
You are afraid of what people might think.	¡	¡	¡	¡
You do not think you are at risk.	¡	¡	¡	¡
You do not want to know the results.	¡	¡	¡	¡
You do not know where to go to get an HIV test.	¡	¡	¡	¡
You do not know what procedures are involved in getting tested (e.g., you do not know what to expect).	¡	¡	¡	¡
You are scared to find out the results.	¡	¡	¡	¡

8. In the next year, how likely is it that you will get tested for HIV?

¡ Very likely

¡ Somewhat likely

¡ Not too likely

¡ Not at all likely

9. If you wanted to get tested for HIV, would you know where to get tested in your community?

¡ Yes

¡ No

In the next section, we’d like to ask about your sexual history and experiences with sexual situations. These questions are very personal. Please remember that all of your answers are private and that YOUR NAME IS NOT ON THIS SURVEY. Please be honest in answering these questions. What you say will help communities develop better HIV prevention programs for American Indian/Alaska Native women.

10. Have you ever had vaginal sex? By vaginal sex, we mean when a man puts his penis into a woman’s vagina.

¡ Yes àCONTINUE TO QUESTION 11

¡ No àSKIP TO QUESTION 21

11. Whether you are HIV positive or negative, do you tell your sexual partner(s) your HIV status?

¡ Yes, I’ve told all of my sexual partners

¡ Yes, I’ve told most of my sexual partners

¡ Yes, I’ve told at least one of my sexual partners

¡ No, I have never told a sexual partner my HIV status

12. Have you ever asked a sexual partner about his HIV status (if he was HIV positive or negative)?

¡ Yes, I’ve asked all of my sexual partners

¡ Yes, I’ve asked most of my sexual partners

¡ Yes, I’ve asked at least one of my sexual partners

¡ No, I’ve have never asked a sexual partner about his HIV status

13. In your lifetime, how many men have you had vaginal sex with? ___________

14. In the past 3 months, how many men have you had vaginal sex with? ___________

15. When you have vaginal sex with a man, about how often do you use condoms?

¡ All the time

¡ Most of the time

¡ Some of the time

¡ Rarely

¡ Never

¡ I am not currently sexually active àSKIP TO QUESTION 21

16. The last time you had vaginal sex with a man, did you or your partner use a condom?

¡ Yes

¡ No

17. The very last time you had sex, what type of protection did you use? (Check all that apply)

¡ I have never had sex àSKIP TO QUESTION 21

¡ Birth control pill

¡ Foam

¡ IUD (Intrauterine device)

¡ Condom

¡ Withdrawal

¡ Spermicide

¡ Depo (3 month shot)

¡ Norplant (5 year implant)

¡ Nuva ring

¡ OrthEvra patch

¡ I didn’t use protection

¡ Other (Please specify) _________________

18. In the past three months, have you ever felt forced or intimidated into having sex without a condom?

¡ Yes

¡ No

The next questions ask about some sexual scenarios where it may be difficult for you to use condoms. Even if the situation has not happened to you, try to imagine how you would handle it if it ever happened.

19. Please read the following situations and indicate your response. (Please select one response per question).

	Definitely NOT	Probably NOT	Probably YES	Definitely YES
Can you discuss condom use with your partner?	¡	¡	¡	¡
Can you insist on condom use if your partner does not want to use one?	¡	¡	¡	¡
Can you stop and look for condoms when you are sexually aroused?	¡	¡	¡	¡
Can you insist on condom use every time you have sex, even when you are under the influence of alcohol or drugs?	¡	¡	¡	¡
Can you insist on condom use every time you have sex even when your partner is under the influence of alcohol or drugs?	¡	¡	¡	¡
Can you put a condom on your partner without spoiling the mood?	¡	¡	¡	¡
Can you insist on condom use every time you have sex even if you or your partner uses another method to prevent pregnancy?	¡	¡	¡	¡

The next questions are about your attitudes and thoughts about using condoms.

20. Please read the following statements and indicate how much you agree or disagree. Please select one option.

	Strongly disagree	Disagree	Neither disagree nor agree	Agree	Strongly agree
My partner would get mad if I said we had to use a condom.	¡	¡	¡	¡	¡
Condoms ruin the mood.	¡	¡	¡	¡	¡
Sex doesn’t feel as good when you use a condom.	¡	¡	¡	¡	¡
My partner would think I was having sex with another person if I said we had to use a condom.	¡	¡	¡	¡	¡
Using condoms would help build trust between my partner and me.	¡	¡	¡	¡	¡
Sex with condoms doesn’t feel natural.	¡	¡	¡	¡	¡
Most of the time, neither my partner nor I have a condom available.	¡	¡	¡	¡	¡
I don’t want to put a condom on my partner.	¡	¡	¡	¡	¡
My partner doesn’t want to use condoms.	¡	¡	¡	¡	¡
If I suggested that we use a condom, my partner would think that I don’t trust him/her.	¡	¡	¡	¡	¡
I usually forget about using condoms.	¡	¡	¡	¡	¡
I can never find a condom right before sex.	¡	¡	¡	¡	¡
I would be afraid to suggest to my partner that we use a condom.	¡	¡	¡	¡	¡
I wouldn’t know where to get a condom.	¡	¡	¡	¡	¡
I would be too embarrassed to buy condoms.	¡	¡	¡	¡	¡
I would be too embarrassed to ask my partner to use a condom.	¡	¡	¡	¡	¡
Condom use is against my religious values.	¡	¡	¡	¡	¡
Condoms cost too much.	¡	¡	¡	¡	¡
I don’t have transportation to buy or get condoms.	¡	¡	¡	¡	¡
I feel closer to my partner if I don’t use a condom.	¡	¡	¡	¡	¡
I don’t need to use a condom, because I never catch anything.	¡	¡	¡	¡	¡
Condoms change the climax or orgasm.	¡	¡	¡	¡	¡
I don’t need to use a condom. I use another method of birth control.	¡	¡	¡	¡	¡
I don’t want to use a condom.	¡	¡	¡	¡	¡

In the next section we’d like to learn a little about your understanding of HIV and its prevention.

21. For each statement, please mark whether you think the statement is true or false or you don’t know.

	True	False	Don’t know
Coughing and sneezing spread HIV.	¡	¡	¡
A person can get HIV by sharing a glass of water with someone who has HIV.	¡	¡	¡
Pulling out the penis before a man climaxes/cums keeps a woman from getting HIV during sex.	¡	¡	¡
A woman CAN get HIV if she has anal sex with a man who is HIV positive. By anal sex, we mean when a man puts his penis into a women’s rectum.	¡	¡	¡
Showering or washing one’s genitals/private parts after sex keeps a person from getting HIV.	¡	¡	¡
All pregnant women infected with HIV will have babies born with HIV.	¡	¡	¡
People who have been infected with HIV quickly show serious signs of being infected.	¡	¡	¡
There is a vaccine that CAN stop adults from getting HIV.	¡	¡	¡
A woman CANNOT get HIV if she has sex during her period.	¡	¡	¡
There is a female condom that CAN help decrease a woman’s chance of getting HIV.	¡	¡	¡
A person will not get HIV if she or he is taking antibiotics.	¡	¡	¡
Having sex with more than one partner CAN increase a person’s chance of being infected with HIV.	¡	¡	¡
Taking a test for HIV one week after having sex will tell a person if she or he has HIV.	¡	¡	¡
A person CAN get HIV from oral sex.	¡	¡	¡
There is a cure for AIDS.	¡	¡	¡
Condoms CAN help protect you from transmitting or becoming infected with HIV.	¡	¡	¡
To know if you have HIV, you have to take a test.	¡	¡	¡
Women CANNOT pass HIV to men.	¡	¡	¡

You are almost finished with the survey. We would like to ask you a few questions about yourself that will help us understand your answers. This information will not be used to identify you or any other person completing the survey.

22. What is your age? _______

23. What is your race? (Select all that apply.)

¡ American Indian

¡Alaska Native

¡ Asian

¡ Black or African American

¡ Native Hawaiian or other Pacific Islander

¡ White

24. Are you Hispanic or Latino?

¡ Yes à CONTINUE TO QUESTION 25

¡ No à SKIP TO QUESTION 26

25. Which Hispanic or Latino group represents you? Are you…

¡ Mexican, Mexican-American, or Chicano

¡ Puerto Rican

¡ Cuban

¡ Dominican

¡ Central American

¡ South American

¡ Other Hispanic Origin, please describe _________________________________________

26. What is your current yearly household income?

¡ 0 – $9,999

¡ $10,000 – $19,999

¡ $20,000 – $29,999

¡ $30,000 – $39,999

¡ $40,000 – $49,999

¡ $50,000 – $59,999

¡ $60,000 and over

27. Please mark the highest grade or year of school you completed.

¡ No high school education

¡ Some high school

¡ High school diploma or GED

¡ Vocational school

¡ Some college

¡ College degree

¡ Some postgraduate work

¡ Master’s degree

¡ Doctoral degree

¡ Other (please specify)­­­­­­­­­­­­_______________________________________________

28. Do you have an exclusive sexual partner?

¡ Yes

¡ No

29. Please mark the answer that best describes your current marital status.

¡ Never married

¡ Married

¡ Married and separated

¡ Divorced

¡ Widowed

¡ Other (please specify)­­­­­­­­­­­­_______________________________________________

30. Are you living with your spouse (or exclusive sexual partner)?

¡ Yes

¡ No

31. Are you currently trying to get pregnant?

¡ Yes

¡ No

32. What language(s) do you speak? (check all that apply)

¡ English

¡ Spanish

¡ American Indian/Alaska Native language

¡ Other (please specify) _________________________________

Thank you for your time and attention to this survey. The information you have provided is extremely important to HIV prevention efforts in American Indian and Alaska Native communities.

Women’s HEAL Survey—Prevention Education Survey (January 2012) Page 11