Survey of Health Care Providers

This survey is being sent to a selected sample of health centers and providers. Please do not distribute to others for completion.

Form Approved

OMB Number: 0920-XXXX

Expiration Date: XX/XX/XXXX

2012–2013 SURVEY of HEALTH CARE PROVIDERS

Public reporting burden of this collection of information is estimated to average 15 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, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-xxxx).

1. PROVIDER, PATIENT and PRACTICE/ HEALTH CENTER CHARACTERISTICS

Please answer each of the following questions as they relate to you, your patients, and the practice/health center at which you received this survey.

1.	Which of the following describes the setting of this practice/health center? (select all that apply)
	Community health center
	Family planning clinic
	Health department (state or local)
	HMO or Hospital
	Indian Health Service
	Planned Parenthood affiliate
	Private practice
	School based health clinic
	Sexually transmitted infection clinic
	University clinic
	Other (please specify)___________________

2.	Does this practice/health center receive any non-fee-for-service income to support family planning services? (select all that apply)
	None
	Private grant(s)
	State appropriations
	Section 308 of Public Health Service Act
	Title V (MCH Block Grant)
	Title X (Family Planning)
	Don’t know
	Other _______________________________

3.	In what state is your practice/health center located? __________________________________

4.	In this practice/health center, how many health care providers, including you, provide family planning services*? _________________________

5.	What is your role as a health care provider? (select one)
	Certified nurse midwife
	Nurse practitioner
	Nurse
	Physician
	Physician assistant
	Other (please specify) ___________________

6.	What is your primary clinical focus at this practice/health center? (select one)
	Adolescent health or pediatrics
	Family medicine
	Obstetrics/gynecology or family planning/reproductive health
	Primary (general health) care
	Other (please specify) ___________________

7.	How many years has it been since you completed your most recent formal clinical training (e.g., medical/nursing school, residency/practicum/ clinical)?
	Less than 5 years
	5-14 years
	15-24 years
	25 or more years

8.	What is your gender?
	Male
	Female

9.	On average, how many female patients of reproductive age do you see per week? ________

10.	To approximately what percent of your female patients of reproductive age do you provide family planning services*?
	0%
	1-24%
	25-49%
	50-74%
	75% or more

* For the purpose of this survey, a family planning service is any service related to postponing or preventing pregnancy. Family planning services may include a medical examination related to provision of a method, contraceptive counseling, method prescription or supply visits. A patient may receive a family planning service even if the primary purpose of her visit is not for contraception.

11.	Have you ever been formally trained in the insertion of the following contraceptive methods for women during the following time periods?
		Trained to insert during routine care		Trained to insert immediately postpartum		Trained to insert immediately post-abortion
		Yes	No	Yes	No	Yes	No
Copper intrauterine device (Cu-IUD or ParaGard®)?
Levonorgestrel-releasing intrauterine device (LNG-IUD or Mirena®)?
Contraceptive implant (Implanon®/Nexplanon®)?				N/A	N/A	N/A	N/A

12.	Approximately what percentages of your female patients of reproductive age have the following characteristics? If unsure, give your best estimate.
		0-24%	25-49%	≥50%
Pay for their visit using Medicaid or other state or federal assistance?
Are racial or ethnic minorities?
Have limited English proficiency?
Are adolescents?
Are 35 years of age or older?

II. HEALTH CARE PROVIDER ATTITUDES

Please answer each of the following questions as they relate to your attitudes when providing family planning services. Please do not consult any source of guidance when answering the questions.

13.	How safe do you consider combined oral contraceptives (COCs) to be for the following groups?
		Very safe	Safe	Unsafe	Very unsafe	Don’t know
Breastfeeding women ≥ 1 month postpartum without other risk factors for venous thromboembolism (VTE)
Smokers 35 years of age or older
Obese women (BMI ≥30 kg/m2)
Women with a history of bariatric surgery via restrictive procedures (e.g., vertical banded gastroplasty)
Women with a history of bariatric surgery via malabsorptive procedures (e.g., Roux-en-Y gastric bypass)
Women with rheumatoid arthritis
Women with inflammatory bowel disease (i.e., ulcerative colitis, Crohn disease) without other risk factors for VTE

14.	How safe do you consider intrauterine devices (Cu-IUD or LNG-IUD) to be for the following groups?
			Very safe		Safe		Unsafe		Very unsafe		Don’t know
Adolescents
Immediately postpartum women (less than 10 minutes after delivery of placenta)
Postpartum women (10 minutes after delivery of placenta to less than 4 weeks postpartum)
Nulliparous women
Obese women (BMI ≥30 kg/m2)
Women with uterine fibroids
Women with HIV (not AIDS)
15.	How safe do you consider DMPA (Depo-Provera®) to be for the following groups?
		Very safe		Safe		Unsafe		Very unsafe		Don’t know
Adolescents
Breastfeeding women <1 month postpartum
Breastfeeding women ≥ 1 month postpartum
Smokers 35 years of age or older
Obese women (BMI ≥30 kg/m2)
Women with a history of bariatric surgery
Women with rheumatoid arthritis not on immunosuppressive therapy
Women with inflammatory bowel disease
Women with complicated diabetes (i.e., nephropathy, retinopathy, neuropathy, other vascular disease or diabetes of >20 years’ duration)

16.	For each of the following contraceptive methods, how safe do you think it is to start a woman on the day of her visit regardless of the timing of her menses (‘Quick Start’) if you are reasonably certain she is not pregnant? Please answer for both adolescents and adults.
		Adolescents			Adults
		Safe	Unsafe	Don’t know	Safe	Unsafe	Don’t know
Combined hormonal contraceptives (COCs, patch, ring)
DMPA
Contraceptive implant
Intrauterine devices (Cu-IUD or LNG-IUD)

III. HEALTH CARE PROVIDER PRACTICES

Please answer each of the following questions as they relate to you (or your clinical team’s) practices when providing family planning services.

17.	In the past month, when counseling your typical female patient of reproductive age on family planning, how often have you (or your clinical team) done the following?
		Very often	Often	Not often	Never
Assessed the patient’s reproductive life plan (i.e., asked about their intentions regarding the number and timing of pregnancies in the context of their personal values and life goals)
Presented information regarding potential contraceptive methods with the most effective methods presented first (tiered approach)
Helped the patient think about potential barriers to using their selected method correctly and develop a plan to deal with these barriers
Used a method-specific informed consent form
Informed adolescents that long-acting reversible contraceptives are safe and effective options

18.	In the past year, how often have you (or your clinical team) provided DMPA to adolescents?
	Very often or often			Go to question #19.
	Not often or never			If “not often or never” please indicate why. (select all that apply)
			a.	I rarely have adolescents as patients
			b.	DMPA is unavailable in my practice/health center
			c.	I am concerned about the safety of DMPA for adolescents
			d.	I am concerned about side effects that may lead to discontinuation
			e.	My adolescent patients generally prefer a different method
			f.	My practice/health center protocol does not allow it
			g.	Other reasons (please specify) ____________________________________

19.	In the past year, how often have you (or your clinical team) provided or prescribed COCs to breastfeeding women ≥ 1 month postpartum without other risk factors for VTE?
	Very often or often			Go to question #20.
	Not often or never			If “not often or never” please indicate why. (select all that apply)
			a.	I rarely have postpartum women as patients
			b.	I am concerned about the safety of COCs for breastfeeding women ≥ 1 month postpartum without other risk factors for VTE
			c.	I am concerned about a decrease in breast milk production
			d.	My postpartum patients generally prefer a different method
			e.	My practice/health center protocol does not allow it
			f.	Other reasons (please specify) ____________________________________

20.	In the past year, how often have you (or your clinical team) provided intrauterine devices (Cu-IUDs or LNG-IUD) to nulliparous women?
	Very often or often			Go to question #21.
	Not often or never			If “not often or never” please indicate why. (select all that apply)
			a.	I rarely have nulliparous women as patients
			b.	IUDs are generally unavailable in my practice/health center
			c.	I am concerned about the safety of IUDs for nulliparous women
			d.	I am concerned about the effects on future fertility
			e.	I am concerned about difficult insertion
			f.	My nulliparous patients generally prefer a different method
			g.	My practice/health center protocol does not allow it
			h.	Cost barriers prevent me from providing IUDs to nulliparous women
			i.	Other reasons (please specify)____________________________________

21.	When initiating the following contraceptive methods, please indicate if you or your practice/health center require the following exams and tests for a healthy client. Please check all exams and tests that apply.
		Blood pressure	Clinical breast exam	Bimanual exam and cervical inspection	Cervical cytology (Pap smear)	Chlamydia/ gonorrhea screening
COCs/patch/ring
Progestin-only pills (POPs)
DMPA
Contraceptive implant
Cu-IUD
LNG-IUD

22.

In the past year, when providing or prescribing combined hormonal contraceptives (COCs, patch, ring), how often did you start a woman on the day of her visit regardless of the timing of her menses (‘Quick Start’) if you were reasonably certain she was not pregnant? Please answer for both adolescents and adults.

(22a) Adolescents
Very often or often			Go to question #22b
Not often or never			If “not often or never” please indicate why. (select all that apply)
a.	I do not think it is safe
b.	I have liability concerns
c.	I do not have enough training
d.	I do not think it is appropriate for adolescents
e.	My practice/health center protocol does not allow it
f.	Other (please specify) ______________

(22b) Adults
Very often or often			Go to question #23
Not often or never			If “not often or never” please indicate why. (select all that apply)
a.	I do not think it is safe
b.	I have liability concerns
c.	I do not have enough training
d.	I do not think it is appropriate for adults
e.	My practice/health center protocol does not allow it
f.	Other (please specify) ______________

23.	In the past year, when providing DMPA, how often did you start a woman on the day of her visit regardless of the timing of her menses (‘Quick Start’) if you were reasonably certain she was not pregnant? Please answer for both adolescents and adults.

(23a) Adolescents
Very often or often			Go to question #23b
Not often or never			If “not often or never” please indicate why. (select all that apply)
a.	I do not think it is safe
b.	I have liability concerns
c.	I do not have enough training
d.	I do not think it is appropriate for adolescents
e.	My practice/health center protocol does not allow it
f.	Other (please specify) ______________

(23b) Adults
Very often or often			Go to question #24
Not often or never			If “not often or never” please indicate why. (select all that apply)
a.	I do not think it is safe
b.	I have liability concerns
c.	I do not have enough training
d.	I do not think it is appropriate for adults
e.	My practice/health center protocol does not allow it
f.	Other (please specify) ______________

24.	After initiating the following methods, please indicate when you advise healthy adult patients to come back for a follow-up visit.
		4-6 weeks	3 months	6 months	12 months	Only if she has problems or questions
COCs, patch, ring
POPs
DMPA (routine follow-up other than for re-injection)
Implant
Intrauterine device (Cu-IUD or LNG-IUD)

25.	In the past year, how often have you or your clinical team done the following?
		Very often	Often	Not often	Never
Provided an advance prescription for emergency contraception (EC) to a woman not specifically seeking EC
Provided an advance supply of EC to a woman not specifically seeking EC
Provided or prescribed a contraceptive at the same time you provided EC
Provided a Cu-IUD as EC

26.	In the past year, how often did you or your clinical team dispense a year’s supply of pills (COCs or POPs) at one visit? Please answer for both new and continuing users.

(26a) New Users
Very often or often			Go to question #26b
Not often or never			If “not often or never” please indicate why. (select all that apply)
a.	I do not think it is safe
b.	My practice/health center does not dispense pills
c.	My practice/health center protocol does not allow it
d.	I have liability concerns
e.	There is not enough supply in my practice/health center
f.	It is too expensive for my practice/health center
g.	I am concerned about wasting pill packs if the woman discontinues
h.	Other (please specify) ______________

(26b) Continuing Users
Very often or often			Go to question #27
Not often or never			If “not often or never” please indicate why. (select all that apply)
a.	I do not think it is safe
b.	My practice/health center does not dispense pills
c.	My practice/health center protocol does not allow it
d.	I have liability concerns
e.	There is not enough supply in my practice/health center
f.	It is too expensive for my practice/health center
g.	I am concerned about wasting pill packs if the woman discontinues
h.	Other (please specify) ______________

27.	For routine health care, at what age do you or your practice/health center recommend that a woman begin routine cervical cancer screening? (select all that apply)
Whenever she becomes sexually active
Starting at age 18
Starting at age 21
Don’t know
Other (please specify) _______________________

28.	For routine health care, how often do you provide cervical cancer screening for a sexually active, 25-year old patient with previously normal results?
Every visit
Annually
Every 2 years
Every 3 years
Don’t know
Other (please specify) _______________________

29.	In general, how important to you are the following sources for staying informed about recommended clinical practices related to contraception? Please answer for each source.
		Important Source	Minor Source	Not Used
Conferences
Continuing education programs
Discussions with colleagues
Internet searches/online resources
Institutional practice protocols
Journals
Medication package inserts
Professional organization publications or notifications
Textbooks (e.g., Contraceptive Technology)
U.S. Medical Eligibility Criteria for Contraceptive Use (MEC)
WHO MEC
WHO Selected Practice Recommendations for Contraceptive Use
Other (please specify): _________________________________

V. AWARENESS OF GUIDELINES

We want to know about your awareness of CDC’s 2010 U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC).

30.	How did you learn about CDC’s 2010 U.S. MEC? (select all that apply)

	I did not know about CDC’s 2010 U.S. MEC before participation in this survey
	Conference attendance
	Continuing medical education programs
	Discussions with colleagues
	Internet searches/online resources
	Institutional practice protocol
	Journals
	Professional organization publications or notifications
	Textbooks (e.g., Contraceptive Technology)
	Other (please specify)______________________________________________________________

31.	Have you used any of the following U.S. MEC materials?
	U.S. MEC website
	U.S. MEC color-coded summary chart in English
	U.S. MEC color-coded summary chart in Spanish
	U.S. MEC wheel
	U.S. MEC PDA application
	U.S. MEC 2011 update with revised recommendations for postpartum contraceptive use
	U.S. MEC 2012 update with revised recommendations for the use of hormonal contraception among women at high risk for HIV infection or infection with HIV

32.	What additional medical conditions or patient characteristics would you like to see recommendations for in the U.S. MEC?
	(please specify) ________________________________________________________________________________
	(please specify) ________________________________________________________________________________
	(please specify) ________________________________________________________________________________

Please share any additional comments that you may have in the space below.

Thank you for completing this survey!

Please return using the enclosed postage paid envelope.

Page 1 of 7