Form Approved
OMB No. 0920-0840
Expiration Date 02/29/2016
Attachment
3a
Pretest Web-based Survey
Pilot Test Study for the HIV Risk Reduction Educational Tool
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).
Introduction and Purpose:
You have been asked to take part in a research study. The purpose of this study is to learn your opinions about HIV prevention materials developed by the Centers for Disease Control and Prevention (CDC). RTI International, a nonprofit research organization in North Carolina, is conducting this CDC-sponsored study.
Procedures:
You will be asked to complete a brief survey so that we can learn more about you. After you complete the survey, you will be asked to review an online HIV prevention tool developed by CDC. You will then be asked to complete another brief survey so that we can learn your opinions about the online tool. The study will take about 45 minutes to complete.
Risks/Discomforts and Right to Refuse or Withdraw:
You might feel embarrassed or upset by some of the survey questions that ask about sexual behavior and alcohol and drug use or by the content of the tool. You can decline to answer any questions for any reason. You can also stop reviewing the tool (click the “Quit Exploring” button) or participating in the study (click the “Quit Study” button) at any time.
Benefits:
There is no direct benefit to you for being in this study. However, you may learn more about ways to prevent getting or giving someone else HIV.
Privacy:
Your responses will be kept private to the extent allowable by law. The survey does ask you for your email address. The survey vendor will send you a reminder email to complete the study if you stop participating before you finish the posttest survey. The survey vendor will also record participants’ IP addresses to help make sure people do not complete the study more than once. Email and IP addresses will be destroyed after all of the data are collected.
Only the survey vendor will know your email and IP address; neither RTI nor CDC will have access to this information. This means that RTI and CDC cannot link your survey answers to you as an individual. To help protect your privacy, we suggest that you participate in the study in a private location – either in your home and/or in a room with a door. Please also close your browser window once you are finished.
Token of Appreciation:
We will give you a $25 Amazon gift card as a token of appreciation. Instructions for redeeming the gift card will be provided after you complete the second survey.
Persons to Contact:
If you have questions about the study, you can call Jennifer Uhrig at 1-800-334-8571, extension 3311. She can be reached between 9 a.m. and 5 p.m., Eastern Standard Time, Monday–Friday. If you have questions about your rights as a participant, you can call RTI’s Office of Research Protection toll-free at 1-866-214-2043. If you have any questions about HIV, including how to locate services and ways to protect yourself, please contact CDC Info (http://www.cdc.gov/cdc-info/). To find local HIV testing sites, health centers, and other service providers, you can also visit AIDS.gov (http://locator.aids.gov/).
Please choose one to continue with the study:
1 I have read this consent form and agree to participate in the study.
2 I have read this consent form and do not want to participate in the study.
Section A: Background Information
First, we are going to ask you some questions to get to know you a little bit.
What is the highest grade or year of school you finished?
1. Never attended school or only attended kindergarten
2. Grades 1 through 8 (elementary)
3. Grades 9 through 11 (some high school)
4. Grade 12 or GED (high school graduate)
5. College 1 year to 3 years (some college or technical school)
6. College 4 years or more (college graduate)
7. Prefer not to answer
Which best describes your total personal income during the past year?
1. Less than $20,000
2. $21,000 to $30,000
3. $31,000 to $40,000
4. $41,000 to $50,000
5. $51,000 or more
6. Prefer not to answer
What is your marital status?
1 Married, civil union, or domestic partnership
2 Unmarried living with a partner or significant other
3 Divorced
4 Widowed
5 Separated
6 Single, never been married
9 Prefer not to answer
Before learning about this study, had you ever heard of CDC or the Centers for Disease Control and Prevention?
1. Yes
2. No [Skip to Q6]
5. Prefer not to answer
How much do you disagree or agree with the following statement: I trust CDC as a source of information about HIV.
Strongly disagree
Disagree
Neither disagree nor agree
Agree
Strongly agree
Prefer not to answer
In this section, we are going to ask you some questions about HIV.
Using a scale from 1 to 10, where 1=I know nothing and 10=I know everything I need to know, please rate your overall knowledge of HIV.
Tell me how risky you think each behavior is for [getting/transmitting] HIV if a person is not using any form of protection. 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 _____
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. Insertive oral sex (“getting a blow job”) with a condom _____
f. Insertive oral sex (“getting a blow job”) without a condom _____
k. Prefer not to answer
Please drag and drop the behaviors below into a box based on how risky you think each behavior is for [getting/transmitting] HIV. Please assume that a person is not using any form of protection from HIV.
Little to no risk |
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High risk |
Highest risk |
a. Deep kissing _____
b. Receptive anal sex (“bottom”) with a condom _____
c. Receptive anal sex (“bottom”) without a condom _____
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. Insertive oral sex (“getting a blow job”) with a condom _____
f. Insertive oral sex (“getting a blow job”) without a condom _____
k. Prefer not to answer
Please indicate how much you disagree or agree with the following statements.
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Strongly Disagree |
Disagree |
Neither Agree nor Disagree |
Agree |
Strongly Agree |
Prefer not to answer |
a. I know all I need to know about HIV. |
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b. I know about how to prevent getting or transmitting HIV. |
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c. I know whether and how often I should be tested for HIV. |
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Please indicate whether the following statements about HIV are true, false, or if you don’t know the answer.
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False |
Don’t Know |
Prefer not to answer |
The window period is the time between when a person gets tested for HIV and when they get back the results. |
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HIV can be transmitted through tears, saliva, or sweat. |
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Antiretroviral therapy (ART) reduces the amount of HIV virus in blood and body fluids. |
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ART reduces the chance of an HIV positive person transmitting HIV to a partner who is negative. |
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When an HIV positive person’s viral load is “undetectable”, they are cured. |
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Withdrawal or pulling out is an effective way to prevent HIV. |
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Heterosexual men who are circumcised are less likely to get HIV from their female sexual partners compared with men who have not been circumcised. |
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Having a sexually transmitted disease (STD) does NOT increase a person’s risk for getting or transmitting HIV. |
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Condoms protect people from every type of sexually transmitted disease. |
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Vaginal sex is riskier for transmitting HIV than anal sex. |
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The chance of getting HIV from oral sex is lower than vaginal sex. |
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Having anal sex without using a condom is the riskiest type of sex for getting or transmitting HIV. |
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People who are HIV negative can take medications (called pre-exposure prophylaxis or PrEP) to prevent getting infected with HIV if they have sex with someone who is HIV positive. |
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A person who has been exposed to HIV can take medications (called post-exposure prophylaxis or PEP) to lower their chances of getting HIV. This only works if they take the medication within 72 hours of being exposed. |
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Please indicate how much you disagree or agree with the following statements.
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Strongly Disagree |
Disagree |
Neither Agree nor Disagree |
Agree |
Strongly Agree |
Prefer not to answer |
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Section C: Sexual Behavior
Next, we are going to ask you some questions about your sexual partners and behaviors.
In the past 12 months, have you had oral sex (mouth on the penis or vagina), vaginal sex (penis in the vagina), or anal sex (penis in the butt)?
1 Yes
2 No
9 Prefer not to answer
Do you currently have a main sexual partner—that is, a partner you would call your boyfriend, girlfriend, spouse, significant other, or life partner?
1 Yes
2 No (SKIP TO Q18)
9 Prefer not to answer (SKIP TO Q18)
[If YES – currently have a main sexual partner] How long have you been in a sexual relationship with your main sexual partner?
Please enter start date: (MM/YYYY) ______________________
9 Prefer not to answer
Do you know the HIV status of your main sexual partner?
1 Yes
2 No (SKIP TO Q17)
9 Prefer not to answer (SKIP TO Q17)
[If YES] What is your main sexual partner’s HIV status?
1 My main partner is HIV negative.
2 My main partner is HIV positive.
3 My main partner has not been tested for HIV.
4 My main partner has not told me his/her HIV status.
9 Prefer not to answer
Have you had sex with another person during the time you have been with your current main sexual partner?
1 Yes
2 No
9 Prefer not to answer
SCRIPT: We’d now like to ask you some questions about casual sexual partners. A non-main or casual sexual partner is someone who you do not consider to be a spouse, significant other, or life partner. In the past 12 months, how many casual (non-main), sexual partners did you have vaginal, anal or oral sex with?
NUMBER __________________
9 Prefer not to answer
[PROGRAMMER: If Q18=0, skip to Q21.]
Do you know the HIV status of your most recent casual (non-main) sexual partner?
1 Yes
2 No (SKIP TO Q21)
9 Prefer not to answer (SKIP TO Q21)
[If YES] What is the HIV status of your most recent casual (non-main) sexual partner?
1 My most recent casual (non-main) sexual partner is HIV negative.
2 My most recent casual (non-main) sexual partner is HIV positive.
3 My most recent casual (non-main) sexual partner has not been tested for HIV.
4 My most recent casual (non-main) sexual partner has not told me his/her HIV status.
Section D: Perceived Risk and Risk Behavior/Personal Prevention Strategies
Thinking about the sex you’ve had over the past 12 months, do you consider yourself to be low, medium or high risk for getting HIV?
1 Low risk
2 Medium risk
3 High risk
9 Prefer not to answer
In the past 12 months, how often did you use condoms for vaginal or anal sex with your current main sexual partner?
1 Always
2 Usually
3 Occasionally
4 Never
9 Prefer not to answer
In the past 12 months, how often did you use condoms for vaginal or anal sex with casual (non-main) sexual partners?
1 Always
2 Usually
3 Occasionally
4 Never
9 Prefer not to answer
Are you currently taking antiretroviral medicines to treat your HIV infection?
1 Yes (SKIP TO Q26)
2 No
9 Prefer not to answer
What is the main reason you are not currently taking any antiretroviral medicines?
1 Not currently going to a health care provider for my HIV infection
2 CD4 count and viral load are good
3 Don't have money or insurance for antiretroviral medicines
4 Don't want to take antiretroviral medicines
5 Other [Specify:_____________________]
9 Prefer not to answer
Have you ever had an HIV viral load test?
1 Yes
2 No [SKIP TO 28]
8 Don’t know [SKIP TO 28]
9 Prefer not to answer [SKIP TO 28]
What was the result of your most recent viral load test?
1 Undetectable
2 Detectable copies/ml
8 Don’t know
9 Prefer not to answer
Before today, have you ever heard of people who do not have HIV taking HIV medicines (PrEP or Truvada) before sex, to keep from getting HIV?
1 Yes
2 No
9 Prefer not to answer
In the past 12 months, have you taken HIV medicines (pre-exposure prophylaxis, PrEP or Truvada) before sex because you thought it would keep you from getting HIV?
1 Yes
2 No
9 Prefer not to answer
Before today, have you ever heard of people who do not have HIV taking HIV medicines (post-exposure prophylaxis, nPEP, or PEP) after sex, to keep from getting HIV?
1 Yes
2 No
9 Prefer not to answer
In the past 12 months, have you taken HIV medicines (post-exposure prophylaxis, nPEP or PEP) after sex because you thought it would keep you from getting HIV?
1 Yes
2 No
9 Prefer not to answer
Section E. Substance Use
In this section, we are going to ask you some questions about your use of alcohol and illicit drugs.
Think specifically about the past 30 days up to and including today. During the past 30 days, on how many days did you drink one or more drinks of an alcoholic beverage? A drink is a can or bottle of beer; a wine cooler or a glass of wine, champagne; a shot of liquor or a mixed drink or cocktail.
Number of days ______
1. Don’t know
2. Prefer not to answer
On the days that you drank during the past 30 days, how many drinks did you usually have each day? A drink is a can or bottle of beer; a wine cooler or a glass of wine, champagne; a shot of liquor or a mixed drink or cocktail.
Number of drinks ______
1. Don’t know
2. Prefer not to answer
Have you ever, even once, used a needle to inject any drug that was not prescribed for you or that you took only for the experience or feeling it caused?
1. Yes
2. No
3. Don’t know
4. Prefer not to answer
In the past 12 months, have you used a needle to inject any drug that was not prescribed for you or that you took only for the experience or feeling it caused?
1. Yes
2. No
3. Don’t know
4. Prefer not to answer
In the past 12 months, have you been drunk or high during sex?
1. Yes
2. No
3. Prefer not to answer
SECTION F: INFORMATION SEEKING
In the past 12 months, how often have you looked for information about…
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Often |
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Never |
Prefer not to answer |
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In the past 12 months, how often have you…
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Section G. Norms
Please tell us how strongly you agree or disagree with the following statements.
Most of my friends and other people close to me… |
Strongly Disagree |
Disagree |
Neither Agree nor Disagree |
Agree |
Strongly Agree |
Prefer not to answer |
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Section H: Self-efficacy for HIV Prevention Behaviors and Informed Decision-Making
Please tell us how strongly you agree or disagree with the following statements.
I am confident that I can… |
Strongly Disagree |
Disagree |
Neither Agree nor Disagree |
Agree |
Strongly Agree |
Prefer not to answer |
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How confident are you that you can…
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Section I. HIV Prevention Behavioral and Informed Decision Making Intentions
Next, we will ask you a few questions about your plans to do or discuss doing various things.
Please tell us how strongly you agree or disagree with the following statements.
I plan to… |
Strongly Disagree |
Disagree |
Neither Agree nor Disagree |
Agree |
Strongly Agree |
Prefer not to answer |
Talk to someone I’m thinking about having sex with about using condoms. |
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Always use condoms correctly with my sex partners. |
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Talk to someone I’m thinking about having sex with about different options to prevent HIV |
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Talk with someone I’m thinking about having sex with about sexually transmitted diseases (STDs) |
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Tell someone I’m thinking about having sex with my HIV status |
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Ask someone I’m thinking about having sex with about their HIV status |
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Get tested for HIV as often as I should. |
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Take my HIV medication (ART) correctly as prescribed by my doctor |
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Find information about the risks of different sexual behaviors |
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Use information about the risks of different sexual behaviors to protect myself from getting or transmitting HIV |
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Use information about the risks of different sexual behaviors to protect my partner from getting or transmitting HIV |
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In what zip code do you currently live? _____
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | kjj9 |
| File Modified | 0000-00-00 |
| File Created | 2021-01-30 |