0920-0572 Attachment 5 - Provider Survey_1_13

CDC and ATSDR Health Message Testing System

Attachment 5 - Provider Survey_1_13

Domestic Readiness Initiative on Zika Virus Disease

OMB: 0920-0572

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OMB No. 0920-0572

Expiration Date 3/31/2018




Submission under

0920-0572 Health Message Testing System



Attachment 5: Provider Message Testing for Zika Response Project

Provider Survey Instrument















Public reporting burden of this collection of information is estimated to average 30 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: OMB-PRA (0920-0572)

ID_____________

Provider Survey

We are interested in your opinions about Zika virus. We would also like to get some additional information about you, your practice and patients. If you’re not sure, choose an answer that comes closest to what you think might be true for each question.


Now that [you/we] are ready to begin, I want to remind you of the following information: There are no costs to you for being in this initiative and your participation is completely voluntary. This survey will take about [30] minutes to complete. The initiative is funded by the Center for Disease Control and Prevention. You may refuse to answer any questions and may choose to stop the survey at any time. The risks to you for participating in this initiative are minimal. You may experience some discomfort when answering some of the more personal questions.


We can assure you that procedures to protect the privacy of your data will be strictly followed, with your answers kept in a secure database only accessible to the researchers working on this study.


Would you like to continue with the [survey]?


Yes____ [CONTINUE]


No____ [THANK/END]


Please see Attachment D for items that will be tested with Health Care Providers



Please see Attachment C for full consent language


I. Patients


We recognize that many healthcare providers split their time between private practices (individual or group) and practices that are public/community or university-based. For the following questions, please provide responses in the table for these practice types as applicable to your own practice of medicine. Please use your best estimate.

Private Practice

Public/Community-based Practice

Private Hospital/University

  1. Number of patients you see in a month.

______

______

______

  1. Number of patients infected with Zika you see in a month.

______

______

______


  1. What percent of your patients are male?


  1. What percent of your patients are female?


  1. How regularly do you/does your health facility take travel histories from patients?

1 Always

2 Very frequently

3 Occasionally

4 Rarely

5 Very rarely

6 Never



II. Zika Clinical Guidance


Please indicate how much you agree or disagree with the following statements about Zika clinical guidance on a scale from 1 to 5, where “1” indicates that you strongly disagree, and “5” indicates that you strongly agree with each statement.


[QUESTIONS MAY BE ADAPTED AND REPEATED FOR EACH CLINICAL GUIDANCE TO BE TESTED SUCH AS ZIKA TESTING, GUIDANCE FOR PRECONCEPTION COUNSELING AND PREVENTION OF SEXUAL TRANSMISSION.]

Strongly Disagree

Somewhat

Disagree

Neither agree nor disagree

Somewhat Agree

Strongly Agree

  1. MMWR guidance for Zika testing is clear and easy to understand.

1

2

3

4

5

  1. My healthcare facility is prepared for Zika patients.

1

2

3

4

5

  1. I am up to date on the MMWR clinical guidelines for Zika.

1

2

3

4

5

  1. I am confident in understanding how to screen patients for Zika

1

2

3

4

5

  1. I am confident in understanding the results for Zika diagnostic testing.

1

2

3

4

5

  1. I have experienced challenges understanding guidance for testing pregnant women for Zika

1

2

3

4

5

  1. MMWR guidance on Zika testing and counseling is easy to understand

1

2

3

4

5

  1. MMWR Guidance for Preconception Counseling and Prevention of Sexual Transmission is clear and easy to understand.

1

2

3

4

5

  1. I am confident that I can apply/use the information in this [SPECIFY] clinical guidance with my patients.

1

2

3

4

5



III. Screening and Testing for Zika Virus


  1. What types of patients do you screen for Zika? [CHECK ALL THAT APPLY]

1 Children

2 Elderly

3 Pregnant women

4 Women of childbearing age

5 Men [specify according to needs of study if: men in a relationship with a pregnant woman, men in relationship with a woman of childbearing age or unspecified]

6 People who live in an area with active transmission of Zika virus

7 People who have travelled to an area with active transmission of Zika virus

8 Couples considering conceiving

9 Other: ____________________[SPECIFY]

10 None of the above


  1. Approximately how many patients have you referred for testing of Zika to your local or state health department?

_______________ [RECORD NUMBER OF PATIENTS] [IF ZERO, SKIP TO 15]

_______________ Don’t know/not sure [SKIP TO 15]

16a. How many of those patients were pregnant women? ____________

16b. How many of those patients were partners of a pregnant women? ____________

16c. How many were travelers? ____________



  1. Approximately how many patients has your healthcare facility referred for testing of Zika to your local or state health department?

_______________ [RECORD NUMBER OF PATIENTS] [IF ZERO, SKIP TO 16]

_______________ Don’t know/not sure [SKIP TO 16]

17a. How many of those patients were pregnant women? ____________

17b. How many of those patients were partners of a pregnant women? ____________

17c. How many were travelers? ____________



  1. What type of diagnostic test for Zika is being used by your local/state health department?

18a. Molecular test for Zika virus? (Trioplex Real-Time RT-PCR Assay)

18b. Serologic test for Zika virus? (Zika MAC-ELISA)

18c. Don’t know/not sure



IV. Attitudes about Zika


Please indicate how much you agree or disagree with the following statements about Zika on a scale from 1 to 5, where “1” indicates that you strongly disagree, and “5” indicates that you strongly agree with each statement.

Strongly Disagree

Somewhat

Disagree

Neither agree nor disagree

Somewhat Agree

Strongly Agree

  1. I think that Zika is a critical issue for my community

1

2

3

4

5

  1. I think Zika will be a critical health issue in my area in summer 2017

1

2

3

4

5

  1. People who do not do something about Zika are selfish

1

2

3

4

5

  1. Zika is a problem in my community

1

2

3

4

5

  1. I know there are steps we can take to prevent Zika

1

2

3

4

5

  1. My community should do more to prevent Zika

1

2

3

4

5

  1. I really don’t care about Zika

1

2

3

4

5


  1. a. Have you talked to your patients about Zika as a potential health issue in summer 2017?

1 Yes [GO TO 26B]

0 No [GO TO 27]


b. What in particular are you telling your patients about Zika as a potential health issue in summer 2017? [OPEN]


  1. For whom do you think Zika will be a critical health issue in summer 2017? [CHECK ALL THAT APPLY]

1 Pregnant women

2 Women wanting to become pregnant

3 Women of child-bearing age (18 – 49 years old)

4 Males in a relationship with women of child-bearing age (18 – 49 years old)

5 Travelers to areas with Zika

6 Other [SPECIFY:_______________]



V. Information Needs and Dissemination


  1. Do you feel like you need Zika-related information about…



Yes

No

  1. Sexual transmission?

1

0

  1. Blood transfusion?

1

0

  1. Diagnostic testing?

1

0

  1. Prevention steps?

1

0

  1. Helping patients modify risky sexual behaviors?

1

0

  1. Symptoms?

1

0

  1. Women who are currently pregnant?

1

0

  1. Women trying to become pregnant?

1

0

  1. Birth defects (e.g. microcephaly)

1

0

  1. Other (SPECIFY) ____________

1

0


  1. How often do you do the following for professional purposes?

Daily

Weekly

Monthly

Less than once per month

Never

  1. Use an app on a mobile device or tablet, such as iPhone, Android phone, iPad, etc.

1

2

3

4

0

  1. Download content to a mobile device or tablet, such as an iPhone, Android phone, iPad

1

2

3

4

0

  1. Print online content such as a medical journal article

1

2

3

4

0

  1. Access medical blogs, such as those available through Medscape or Sermo

1

2

3

4

0

  1. Use social media, like Twitter or Facebook

1

2

3

4

0

  1. Use medical social media like Epocrates

1

2

3

4

0

  1. Listen to podcasts

1

2

3

4

0

  1. Other (SPECIFY) ____________________

1

2

3

4

0


  1. What type of resources would be most helpful to your practice to help with Zika virus counseling and testing? [CHECK ALL THAT APPLY]

1 Training on Zika prevention

2 Training on Zika testing

3 Access to patient education materials

4 Scripts of what to say to patients

5 Other [SPECIFY:_______________]


VI. Patient Resources and Communication


  1. When do you talk to your patients about Zika?

1 Never [SKIP TO Q 31]

2 If they ask me for information

3 If they are at risk (pregnant, travelers, live in area with local transmission)

4 At every visit


  1. What do you discuss with your patients who are pregnant women and who are at risk of Zika exposure (e.g., travel/partner travel, living in an area with Zika transmission) about preventing Zika virus infection? [CHECK ALL THAT APPLY]

1 Do not discuss

2 Discuss Zika virus infection in pregnancy

4 Recommend mosquito bite prevention

5 Recommend delaying travel to areas with Zika

6 Recommend condom use with a male partner

7 Recommend abstinence from having sex with a male partner

8 Discuss options for terminating pregnancy

9 Do not have any female patients at risk of Zika exposure



  1. What do you discuss with your patients who are women of reproductive age and who are at risk of Zika exposure (e.g., travel/partner travel, living in an area with Zika transmission) about preventing Zika virus infection? [CHECK ALL THAT APPLY]

1 Do not discuss

3 Recommend contraception if pregnancy is not desired

4 Recommend mosquito bite prevention

5 Recommend delaying travel to areas with Zika

6 Recommend condom use with a male partner

7 Recommend abstinence from having sex with a male partner

8 Recommend delaying pregnancy

9 Do not have any female patients at risk of Zika exposure


  1. What do you tell your other patients, (i.e., patients who are not women of reproductive age) who are not at risk of Zika exposure about preventing Zika virus infection? [CHECK ALL THAT APPLY]

1 Do not discuss

2 Explore reproductive life plans

3 Discuss Zika virus infection in pregnancy

4 Recommend contraception if pregnancy is not desired

5 Recommend mosquito bite prevention

6 Recommend delaying travel to areas with Zika

7 Recommend condom use with male partner who has traveled to areas with Zika

8 Recommend abstinence from having sex with a male partner who has traveled to areas with Zika


  1. What, if anything, do you advise your [male/female] patients about Zika who are currently trying to conceive/become pregnant? [OPEN]


  1. What, if anything, do you advise your pregnant patients about Zika? [OPEN]


  1. What, if anything, do you advise your patients about sexual transmission of Zika? [OPEN]


  1. Do you refer your patients to the following resources for Zika…

Yes

No

  1. Your practice’s website?

1

0

  1. CDC’s website?

1

0

  1. Other websites [SPECIFY:_______________]?

1

0

  1. Other electronic resources [SPECIFY:_______________]?

1

0

  1. Hotlines or telephone resources? [SPECIFY:_____________]?

1

0

  1. Other [SPECIFY:_______________]?

1

0


  1. Do you provide printed materials about Zika to your patients?

1 Yes [IF YES:] What are the sources of these materials? [OPEN]

0 No [IF NO:] What are the reasons you do not provide printed materials to your

patients? [OPEN]


  1. What challenges, if any, prevent you from having discussions regarding high-risk sexual behaviors with your patients who have been infected with Zika? [CHECK ALL THAT APPLY]

1 Lack of time

2 Lack of knowledge about Zika

3 Cultural difference between you and your patient

4 Gender difference between you and your patient

5 Lack of trust/relationship with patient

6 Lack of skills or training in this area

7 Patients are uncomfortable discussing the subject

8 I am uncomfortable discussing the subject

9 Other [SPECIFY:_______________]

0 There are no challenges to such discussion that I can identify


  1. Which ONE of these sources do you trust the most for receiving information about Zika virus? [CHECK ONE]

1 Consultation with colleagues

2 Professional journals

3 Professional associations

4 Health care provider websites

5 The CDC’s telephone information line [800-CDC-INFO] or website

6 Other website(s) [SPECIFY:_______________]

7 My state/local health department

8 Television or radio news

9 Online news sources

10 Social network sites like Facebook

11 Other [SPECIFY:_______________]

0 None of these

99 Prefer not to answer



VII. Continuing Medical Education (CME)


  1. Would you only attend a training/conference/webinar about Zika if you knew you could obtain CME credit?

1 Yes

0 No


  1. Select the top three Zika-related topics that are of interest to you. [CHECK UP TO THREE]

1 Zika and sexual transmission

2 Zika and blood transfusion

3 Conducting Zika testing

4 Prevention steps

5 Helping patients modify risky sexual behaviors

6 Symptoms

7 Women currently pregnant

8 Women trying to become pregnant

9 Other [SPECIFY:_______________]



VIII. Materials/Message/Concept Testing


  1. Please indicate how much you agree or disagree with the following statements about the health messaging included in the [INSERT MATERIAL TYPE]. On a scale from 1 to 5, where “1” indicates that you strongly disagree, and “5” indicates that you strongly agree with each statement.


[ROTATE #MATERIALS/MESSAGE/CONCEPT AND ASK #37-39 FOUR TIMES]

Strongly Disagree

Somewhat

Disagree

Neither agree nor disagree

Somewhat Agree

Strongly Agree

  1. Overall, I liked this [INSERT MATERIAL TYPE

1

2

3

4

5

  1. I was interested in reading this [INSERT MATERIAL TYPE]

1

2

3

4

5

  1. This [INSERT MATERIAL TYPE] was made for a person like me

1

2

3

4

5

  1. This [INSERT MATERIAL TYPE] was easy to understand

1

2

3

4

5

  1. I like the way this [INSERT MATERIAL TYPE] looks

1

2

3

4

5

  1. I liked the colors in this [INSERT MATERIAL TYPE]

1

2

3

4

5

  1. I trust the information in this [INSERT MATERIAL TYPE]

1

2

3

4

5

  1. I can do what this [INSERT MATERIAL TYPE] suggests

1

2

3

4

5

  1. I will do what this [INSERT MATERIAL TYPE] suggests

1

2

3

4

5

  1. This [INSERT MATERIAL TYPE] grabbed my attention

1

2

3

4

5

  1. This [INSERT MATERIAL TYPE] was confusing

1

2

3

4

5

  1. The [INSERT MATERIAL TYPE] was convincing

1

2

3

4

5

  1. This [INSERT MATERIAL TYPE] said something important to me

1

2

3

4

5

  1. This [INSERT MATERIAL TYPE] told me something I didn’t already know

1

2

3

4

5

  1. This [INSERT MATERIAL TYPE] will help me answer my patients’ questions about Zika

1

2

3

4

5

  1. I do not like this [INSERT MATERIAL TYPE]

1

2

3

4

5

  1. The message about Zika was compelling

1

2

3

4

5

  1. The message was weak

1

2

3

4

5

  1. The [INSERT MATERIAL TYPE ] contained information that will help me answer my patients’ questions

1

2

3

4

5


  1. How could these [INSERT MATERIAL TYPE] be improved? [OPEN]


Ranking of Materials



  1. Please rank these four [INSERT MATERIAL TYPE] by placing a 1 by the [INSERT MATERIAL TYPE] you felt was the most memorable, a 2 by your second-most memorable, etc.  Number 4, then, would be the ad you felt was the least memorable.


[RANKING QUESTION UP TO TOP 4, FORCE EXACTLY ONE RESPONSE FOR EACH OF 1 THROUGH 4.  RANDOMIZE 1-4.]


1 Picture/description of first ad viewed

2 Picture/description of second ad viewed

3 Picture/description of third ad viewed

4 Picture/description of fourth ad viewed


  1. Please rank these four [INSERT MATERIAL TYPE] by placing a 1 by the [INSERT MATERIAL TYPE] you felt was the most effective in motivating you or someone else to [INSERT BEHAVIOR] Zika, a 2 by the second-most effective in motivating you to [INSERT BEHAVIOR].  Number 4, then, would be the [INSERT MATERIAL TYPE] you felt was the least effective.


[RANKING QUESTION UP TO TOP 4, FORCE EXACTLY ONE RESPONSE FOR EACH OF 1 THROUGH 4.  RANDOMIZE 1-4.]


1 Picture/description of first [INSERT MATERIAL TYPE] viewed

2 Picture/description of second [INSERT MATERIAL TYPE] viewed

3 Picture/description of third [INSERT MATERIAL TYPE] viewed

4 Picture/description of fourth [INSERT MATERIAL TYPE] viewed



IX. Demographics


  1. What language are you most comfortable with?

1 English

2 Spanish

3 English and Spanish equally

4 Other


  1. What is your age?

__________ [RECORD AGE]


  1. What is your gender?

1 Male

2 Female

99 Prefer not to answer


  1. Are you Hispanic or Latino/a?

1 Yes

0 No

99 Prefer not to answer


  1. In what country were you born?

1 United States

2 United States Territory

3 Mexico

4 Cuba

5 Colombia

6 Other [SPECIFY:_______________]

9 Prefer not to answer


47a. [IF 47 = UNITED STATES] In what state were you born? __________ [SPECIFIC STATES TO BE PROGRAMMED]


47b. [IF 47= UNITED STATES TERRITORY] In what territory were you born?

1 American Samoa

2 Guam

3 Northern Mariana Islands

4 Puerto Rico

5 U.S. Virgin Islands


  1. What is your race? [CHECK ALL THAT APPLY]

1 American Indian or Alaska Native

2 Asian

3 Black or African American

4 Native Hawaiian or Other Pacific Islander

5 White

99 Prefer not to answer



Thank you for your time. Your thoughts and opinions are very important to us.

17

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