Development of CDC's Act Against AIDS Social Marketing Campaigns Targeting Consumers

Form Approved

OMB No. 0920-0840

Exp. Date 02/29/2016

Submission 0920-13ABP under

0920-0840 Formative Research and Tool Development

Attachment 2q: Paper and Pencil - HIV Prevention

Survey Instrument

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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0840).

Attachment 2q: Paper and Pencil- HIV Prevention

CASE ID_____________

PARTICIPANT SURVEY

We are interested in your opinions about HIV prevention. We would also like to get some additional information about you. If you’re not sure, choose an answer that comes closest to what you think might be true for each question. Please remember that your answers are private. You can choose not to answer any question and can stop at any time. When you are finished with the survey, please place it in the envelope.

Demographics

1. How old are you?

Age__________

a. Refuse to answer

2. What is your gender?

a. Male

b. Female

c. Transgender or Transsexual

d. Other [Specify: ] [Terminate]

e. Don’t know [Terminate]

f. Refuse to answer [Terminate]

3. Are you Hispanic or Latino/a

a. ____No

b. ____Yes

c. Prefer not to answer

3. What is your race? (One or more categories may be selected)

a. ____White

b. ____Black or African American

c. ____American Indian or Alaska Native

d. ____Asian

e. ____Native Hawaiian or Other Pacific Islander

f. Prefer not to answer

5. What is the highest grade or year of school you finished?

a. Never attended school or only attended kindergarten

b. Grades 1 through 8 (elementary)

c. Grades 9 through 11 (some high school)

d. Grade 12 or GED (high school graduate)

e. College 1 year to 3 years (some college or technical school)

f. College 4 years or more (college graduate)

g. Refuse to answer

6. Which best describes your total personal income during the past year?

a. Less than $20,000

b. $21,000 to $30,000

c. $31,000 to $40,000

d. $41,000 to $50,000

e. $51,000 or more

f. Refuse to answer

7. Which do you consider yourself to be?

a. Gay, lesbian, homosexual, or same gender loving

b. Bisexual or two spirited

c. Straight or heterosexual

d. Other [Specify:__________]

e. None of the above/unsure

f. Refuse to answer

8. What is your current relationship status? Are you…?

a. [Single]

b. [Married to a man]

c. [Married to a woman]

d. [In a relationship with a man]

e. [In a relationship with a woman]

f. [Divorced or widowed]

g. Refuse to answer

9. In what ZIP code do you currently live? _________

10. Before being contacted for this study, had you ever heard of CDC or the Centers for Disease Control and Prevention?

a. Yes

b. No

e. Refuse to answer

Sources of Information

The first set of questions asks about how you may get certain kinds of information.

11. Please tell us whether you’d be interested in getting information about HIV prevention from each of the following sources. [MARK ALL THAT APPLY]

	Yes	No
a. Community health clinic
b. Doctor’s office
c. Church
d. Health fair
e. Work
f. Sporting event
g. Night club
h. [Gay bookstore]
i. Coffee shop
j. Clothing store
k. Health club or gym
l. [Choirs or choruses]
m. Shopping malls
n. [Black pride events]
o. [Circuit Parties (Sizzle Miami, Houston Splash, Oasis, Datboi Spring Fling Las Vegas, Fire Island Black Out, St. At Large)]
p. [Balls]
q. [Sex shops]
r. [Bath houses]
s. [Clubs/party promoters (Men are from Mars, Wassup N ATL)]
t. [Gay newspaper]

12. Do you use the Internet?

a. Yes

b. No (Skip to Question 16)

13.

15. How often do you visit the following Web sites?

	Daily	2 -5 Times a week	Once a week	2-3 Times a month	Once a month	Less than once a month	Never
a. Facebook (www.facebook.com)
b. Myspace (www.myspace.com)
c. YouTube (www.youtube.com)
d. [insert]
e. [insert]
f. [insert]
g. [insert]
h. [insert]
i. [insert]
j. [insert]
k. Other: [Specify:__________]
l. Other: [Specify:__________]

16.

Behaviors

These next few questions are about your personal behaviors, including sexual activity. Please remember that your answers are kept private.

Sexual Activity

21.

25. Did you have [oral/vaginal/anal sex] with any of your [female/male] partner(s) in the past [INSERT TIME FRAME]?

a. Yes

b. No

c. Refuse to answer

26. When you had [oral/vaginal/anal] sex with your [female/male] partner(s) in the past [INSERT TIME FRAME], how often did you and your partner use a condom?

a. Never used a condom

b. Occasionally used a condom

c. Usually used a condom

d. Always used a condom

e. Refuse to answer

27. In the past [INSERT TIME FRAME], did you ever, even one time, have sex without a condom?

a. Yes

b. No

d. Refuse to answer

28. In the past 30 days, have you been drunk [or buzzed from alcohol] or high during sex?

a. Yes

b. No

c. Refuse to answer

Sexual Partners

29 Do you currently have a main sex partner—that is, a partner you would call your spouse, significant other, or life partner?

a. Yes

b. No

c. Refuse to answer

30.

31. Is your main partner male, female, or transgender?

a. Male

b. Female

c. Transgender

d. Refuse to answer

32. What is your main partner’s HIV status?

a. My main partner is HIV negative

b. My main partner is HIV positive

c. My main partner has not been tested for HIV

d. My main partner has not told me his or her HIV status

e. Refuse to answer

33. Does your main partner know your HIV status?

a. Yes

b. No

c. Refuse to answer

34. In the past 12 months, how many non-main partners – that is, somebody who you did not consider to be a spouse, significant other, or life partner – did you have oral, vaginal, or anal sex with?

a. 0

b. 1-5

c. 6-10

d. 11-15

e. 16-20

f. Over 20

g. Refuse to answer

35. Did you have unprotected [vaginal/anal] sex with any [female/male] partners in the past 12 months whose HIV status you didn’t know? By unprotected sex, I mean [oral/vaginal/anal] sex when you or your partner didn’t use a condom.

a. Yes

b. No

c. Refuse to answer

36. Did you have unprotected [vaginal/anal] sex with any [female/male] partners in the past 12 months who you knew or thought to be HIV positive? By unprotected sex, I mean [oral/vaginal/anal] sex when you or your partner didn’t use a condom.

a. Yes

b. No

c. Refuse to answer

37.

Risk

39. Thinking about the sex you’ve had over the past (insert time frame), do you consider yourself to be high, medium or low risk for [getting or giving] HIV?

a. Low risk

b. Medium risk

c. High risk

d. Refuse to answer

40. If you don’t change any HIV-related behaviors what is your chance of getting HIV disease in the next (insert time period here)?

a. 0-24% or have little to no chance of getting it

b. 25-49% or have some chance of getting it

c. 50% or have equal chance of getting it or not getting it

d. 51-74% or have a good chance of getting it

e. 75-100% or it is likely that I will get it

f. Refuse to answer

41. Tell me how risky you think each behavior is for [getting or giving] HIV. Use a scale where 0 is lowest risk and 100 is highest risk. Please assign any number in that range to each of the behaviors listed.

a. [Deep kissing]

b. [Receptive anal sex (“bottom”) with a condom]

c. [Receptive anal sex (“bottom”) without a condom]

d. [Mutual masturbation]

e. [Receptive oral sex (“giving a blow job”) with a condom]

f. [Receptive oral sex (“giving a blow job”) without a condom]

g. [Insertive anal sex [(“top”)] with a condom]

h. [Insertive anal sex [(“top”)] without a condom]

i. [Vaginal sex with a condom]

j. [Vaginal sex without a condom]

k. [Other behavior]

l. Refuse to answer

HIV Testing

45. Have you ever been tested for HIV?

a. Yes

b. No

c. Don’t know

d. Refuse to answer

46. When was your last HIV test?

a. 0–2 months ago

b. 3–6 months ago

c. 7–12 months ago

d. More than 12 months ago

e. Don’t know

f. Refuse to answer

47. How often do you get an HIV test?

a. Every 0-2 months

b. Every 3-6 months

c. Every 7-12 months

d. Less often than once a year

e. Other [Specify: ]

f. Don’t know

g. Refuse to answer

HIV Protective Behavioral Intentions

48. Do you plan to [HIV prevention strategy] the next time you have sex?

a. Yes

b. No

e. Refuse to answer

49. If your sexual partner does not want to [insert HIV prevention strategy], do you plan on insisting that the two of you [HIV prevention strategy]?

a. Yes

b. No

e. Refuse to answer

50. The next time you have sex, do you plan on talking about [HIV prevention strategy] with your partner?

a. Yes

b. No

e. Refuse to answer

51. How likely are you to (put example preventive action here) the next time you (add specific behavior here/have sex)?

a. Very unlikely

b. Unlikely

c. Neither unlikely or likely

d. Likely

e. Very likely

f. Refuse to answer

Norms and Attitudes

Most of my friends …

	Strongly Disagree	Disagree	Neither Disagree Nor Agree	Agree	Strongly Agree	Refuse to Answer
a. think you should always use condoms when having anal sex with a new partner.	1	2	3	4	5	9
b. use condoms for anal sex.	1	2	3	4	5	9
d. think negatively of me if I do not use condoms when I have anal sex.	1	2	3	4	5	9

How sure are you that you could use a condom the next time you have anal sex with a partner whose HIV status you do not know?

₁ Very sure I could not

₂ Somewhat sure I could not

₃ Neither unsure nor sure I could

₄ Somewhat sure I could

₅ Very sure I could

₉ Refuse to answer

52. Most people who are important to me think I should [insert behavior here]. By important to me, we mean people like friends, family, and anyone else who is an important part of your life.

a. Strongly disagree

b. Disagree

c. Neither disagree nor agree

d. Agree

e. Strongly Agree

f. Refuse to answer

53. Most of my sexual partners [insert behavior here].

a. Strongly disagree

b. Disagree

c. Neither disagree nor agree

d. Agree

e. Strongly Agree

f. Refuse to answer

54. Most [gay men/people I know] [insert behavior here].

a. Strongly disagree

b. Disagree

c. Neither disagree nor agree

d. Agree

e. Strongly Agree

f. Refuse to answer

55. On a scale from 1 to 6, where 1 is extremely bad and 6 is extremely good, how would you rate [insert behavior here].

a. Extremely bad

b. Bad

c. Neither bad nor good

d. Good

e. Extremely good

f. Refuse to answer

56. On a scale from 1 to 6, where 1 is extremely harmful and 6 is extremely beneficial, how would you rate [insert behavior here] to [prevent HIV]?

a. Extremely harmful

b. Harmful

c. Neither harmful nor beneficial

d. Beneficial

e. Extremely beneficial

f. Refuse to answer

57. Please tell us how much you disagree or agree with the following statements

a. [insert behavior here] is expensive.

b. [insert behavior here] is inconvenient.

c. [insert behavior here] allows me to have unprotected sex with partners who are [HIV negative or HIV positive]

d. [insert behavior here] [insert descriptor here].

e. Strongly disagree

f. Disagree

g. Neither disagree nor agree

h. Agree

i. Strongly Agree

j. Refuse to answer

58. How sure are you that you could [insert behavior here] if…

	Very sure I could not	Somewhat sure I could not	Slightly sure I could	Somewhat sure I could	Very sure I could
a. you wanted to [insert behavior here]?
b. [insert circumstance]?
c. [insert circumstance]?
d. [insert circumstance]?
e. [insert circumstance]?

59. I feel confident in my ability to [insert HIV prevention strategy here].

a. Strongly disagree

b. Disagree

c. Neither agree or disagree

d. Agree

e. Strongly agree

60. Listed below are a variety of thoughts that may pop into people’s heads when they are thinking about having unsafe sex with either a main or casual partner. Please tell us how often you have had these thoughts.

	Never thought	Very occasionally think	Occasionally think	Frequently think	Very frequently think
a. He looks so healthy, he can’t possibly be HIV positive
b. He can’t be HIV positive because he is willing to have sex without a condom
c. He seems intelligent/well-educated, so I’m sure he has been careful
d. I’m sure he isn’t infected
e. My positive state of mind can prevent me from being infected
f. I’m too healthy to become infected
g. I’ve been lucky so far, I’m sure I’ll continue to be lucky
h. I don’t care if I become HIV positive
i. People who are HIV positive would insist on using a condom
j. My regular partner only has unsafe sex with me, so I’m safe
k. I believe him when he says he is negative
l. I’m always the active/ insertive/penetrative partner, therefore I’m safe
m. [insert other reason]

Positive Attitudes toward Talking about HIV with Partners, Peers, and Family

61. It is important to talk about [HIV].

a. Strongly disagree

b. Disagree

c. Neither disagree nor agree

d. Agree

e. Strongly agree

f. Refuse to answer

62. It is important to talk about [HIV] with [INSERT].

a. Strongly disagree

b. Disagree

c. Neither disagree nor agree

d. Agree

e. Strongly agree

f. Refuse to answer

63. I am confident that I can talk to [INSERT] about [INSERT].

a. Strongly disagree

b. Disagree

c. Neither disagree nor agree

d. Agree

e. Strongly agree

f. Refuse to answer

IDENTITY and Discrimination

This next set of questions asks about how you identify in terms of race and sexual orientation. Some of the questions also ask about your experiences with how others have reacted to your race and/or sexual orientation.

64. Please tell us how much you disagree or agree with each of the following statements.

	Do not agree at all 1	2	3	4	5	6	Agree Completely 7
a. I feel good about being a [insert race/ethnicity/sexual orientation].
b. I often regret that I am a [insert race/ethnicity/gender]
c. In general, I am glad to be a [insert race/ethnicity/sexual orientation]
d. Overall, I often do not like being a [insert race/ethnicity/sexual orientation]
e. Being a [insert race/ethnicity/sexual orientation] is important to me
f. If someone says something bad about [insert race/ethnicity/sexual orientation]they say something bad about me

The End

Thank you for answering these questions. Please place the survey in the envelope provided. Give the survey and your consent form to the interviewer when you go into the interview room. The interviewer will not see your responses to these questions.

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