Form Approved
OMB No. 0990-
Exp. Date XX/XX/20XX
Key Persons, Coalition Members, and Community Leaders Online Survey
Introduction and Informed Consent: You received this survey, because you have participated as a member of or have been involved in an activity sponsored by the [Coalition] in your community. If you are 18 years or older, keep reading. Your participation is voluntary. You can skip any item you want to without penalty to you or your organization. There are little risks for your participation. Please provide honest responses and complete information. This will help the [coalition] and the U. S. Department of Health and Human Services, Office on Women’s Health in improving women and girls’ health. If you do not know the coalition, this should take about 10 minutes. If you do know the coalition, this should take about 20 minutes. Do not put your name on the survey or any other identifying information (other than your gender and length of time in the community, where asked). This will help us to understand the responses overall. We will mix your responses in with dozens of others and report them so that you cannot be identified. If you would like more information about this survey and your participation, please contact Dr. Suzanne Randolph at The MayaTech Corporation by email ([email protected]) or telephone (301-587-1600). She is the lead evaluator. Your local contact is: [name, title, email and/or phone]. If you have any questions regarding your participation or any aspect of this survey, please email Dr. Randolph or email Ms. Valerie Spencer ([email protected]; or call (301) 587-1600). She is President and Institutional Review Board Manager at MayaTech.
If you agree to participate in this survey, please indicate that you are 18 years or older and click “yes” below. You will, then, be directed to the survey.
If you do not agree to participate in this survey, click “No.”
I am 18 years of age or older ___YES (CONTINUE) NO___ (send to end of survey and out)
___YES, I want to participate. (CONTINUE)
___NO, I do not want to participate. (SEND TO END AND OUT OF SURVEY)
Thank you in advance for your cooperation.
INTRODUCTION
The coalition supports activities for the larger community and specific women and men in your community. This survey is about your views on your community’s response to the health needs of females and males. We also want to know your views on the overall health of females and males in your community. You do not need to know the activities of the coalition to answer these items. We would like your general views at this point in time. We also ask about your views on the coalition’s activities. Finally, we ask about your views on ways organizations address health needs in your community.
Form Approved
OMB No. 0990-
Exp. Date XX/XX/20XX
Section I. Perceptions of ways in which the community addresses the health needs of women/girls and men/boys
In this section, we are interested in your perceptions of the extent to which organizations and agencies in your community address the health needs of women/girls and men/boys and provide opportunities for their participation in health-related activities and decision-making. Please select one response which best reflects the extent to which you agree or disagree with the item.
1—I Strongly Disagree. 2—I Disagree. 3—I Somewhat Disagree. 4—I am Undecided. 5-I Somewhat Agree. 6—I Agree. 7—I Strongly Agree. 0—I Don’t Know.
In our community:
Women and men get the same benefit from health activities.
Women participate more than men in health activities.
Health activities in our community address differences between women's and men's roles.
Women have the resources they need to participate in health programs.
Health activities in our community take into account that women have needs different than men.
Health activities are supporting negative ideas about what women can do.
Organizations and agencies are working to reduce negative ideas about what women can do.
Organizations and agencies conduct activities that help community members to be more sensitive to what both men and women need to live healthier and happier lives.
Women contribute to the political decision-making in this community.
Women in this community get paid less than men for doing the same work.
Residents are aware of the difference between “sex” and “gender.”
Residents know about major differences between men’s and women’s health.
Section II. Perceptions of Coalition Activities
This set of items is about the coalition’s activities and programs.
13. To what extent would you say the larger community is aware of the activities and programs of the coalition [list name, social media campaign and popular name here for reference for each grantee’s survey]?
1—Not at all aware 2—Somewhat aware 3—Aware 4—Very aware
14. How familiar are you with the activities and programs of the coalition [list name, social media campaign and popular name here for reference for each grantee’s survey]?
__1--Not at all familiar (SKIP next section and go to demographics, then submit)
__2--Somewhat familiar
__3--Familiar
__4--Very familiar
Form Approved
OMB No. 0990-
Exp. Date XX/XX/20XX
If you answered “somewhat familiar,” “familiar” or “very familiar” to item #14 above, please continue. This set of items asks about coalition activities.
For each of the following items, please provide the response that best reflects your perception for that item.
1—I Strongly Disagree. 2—I Disagree. 3—I Somewhat
Disagree.
4—I am Undecided. 5-I Somewhat Agree. 6—I
Agree.
7—I Strongly Agree. 0—I Don’t Know.
15. Women were included in the coalition activities as beneficiaries at all levels.
16. Women and men contribute at about the same level in implementing coalition activities.
17. Women and men benefit about the same from coalition activities.
18. There are adequate resources available to women to participate in coalition activities.
The coalition activities address gender inequities in women's and men's roles and responsibilities.
There are possible unplanned effects and outcomes that might be negative for women.
The coalition has adequate gender-based approaches to address the gender-based needs of women and girls.
The coalition’s activities are eliminating or reducing negative gender stereotypes.
The coalition’s activities can be easily tried out by organizations that have not been participating as partners.
Provide the answer that best fits your views about the coalition activities.
1—I Strongly Disagree. 2—I Disagree. 3—I Somewhat
Disagree.
4—I am Undecided. 5-I Somewhat Agree. 6—I
Agree.
7—I Strongly Agree. 0—I Don’t Know.
It's easy to participate in the coalition activities.
It's easy for a man or boy to participate in the activities.
It's easy for a woman or girl to participate in the coalition activities.
The coalition activities fit with the lifestyles of the participants.
Others can easily see the benefits for women and girls.
I would recommend the coalition activities to other community members.
Others can see the difference that the coalition is making in improving women and girls’ health.
Others can see the difference that the coalition is making in changing negative ideas about women and girls.
I would recommend the coalition activities to other communities for implementation.
The coalition’s activities are resulting in improved health for women and girls.
To what extent can the activities or programs of the coalition be sustained over time?
1—Not at all 2—Somewhat 3—A great extent
Form Approved
OMB No. 0990-
Exp. Date XX/XX/20XX
Section III. About the Coalition: For Coalition Representatives or Interested Individuals on Coalition
Were you a representative for your organization or did you serve as an interested individual on the [coalition name]?
__NO (SKIP and go to Section V. Background)
__YES, as an organizational representative from the grantee organization]--CONTINUE
__YES, as an organizational representative (not the grantee organization)--CONTINUE
__YES, as an interested individual—CONTINUE
For each of the following, please indicate the response that best fits your perception:
1—I Strongly Disagree. 2—I Disagree. 3—I Somewhat
Disagree.
4—I am Undecided. 5-I Somewhat Agree. 6—I
Agree.
7—I Strongly Agree. 0—I Don’t Know.
Women are included as stakeholders in project identification and design meetings.
Women and men attend coalition meetings with about the same frequency.
Men and women contribute at about the same level to coalition decision making.
Women and men contribute at about the same level in implementing coalition activities.
There is an adequate number of women involved in important decision-making for the coalition.
The possible negative unplanned effects for women have been addressed.
Organizations and institutions with a gender mandate are included on the coalition.
Appropriate budget allocations were made to allow for the successes for men/boys.
Appropriate budget allocations were made to allow for the successes of women/girls.
The coalition disaggregates (breaks up and reports) data by sex in order to allow for ongoing analysis and improvements.
The coalition links its monitoring and evaluation indicators to the relevant national goals such as those set by Healthy People 2020 Objectives/topic areas.
The coalition is having the intended impact on the target community.
To what extent was there political support for the program from:___?
1—To little or no extent 2--Somewhat 3—A great deal
the applicant organization’s leadership senior/executive management?
the applicant organization’s leadership Board?
senior management or board of partnering organizations?
grassroots organizations participating in the coalition?
local elected officials or governing bodies?
To what extent was this initiative a multi-sectoral effort?
1—To little or no extent 2--Somewhat 3—A great deal
Have you or your organization leveraged the resources of the coalition or your participation in the coalition to implement gender-based activities, expand the activities of the coalition, acquire new resources, or in other ways?
___NO (skip to Section IV)
___YES: In what ways? ___________________
Form Approved
OMB No. 0990-
Exp. Date XX/XX/20XX
SECTION IV. Coalition Category
Below are five categories into which coalitions doing this type of work could be grouped and a description for each. After reading each description, please check which category best describes the one in which you believe your coalition is functioning. CHECK ONLY ONE CATEGORY (THE ONE THAT BEST DESCRIBES YOUR COALITION OVERALL).
___A: Program approaches reinforce inequitable gender stereotypes, or disempower certain people in the process of achieving program goals. They can do harm by reinforcing negative behaviors and attitudes. Example: A program that reinforces women’s role as children’s caretakers by making children’s health services unfriendly toward fathers, rather than encouraging equality in parenting responsibilities.
___B: Program approaches or activities do not actively address gender stereotypes and discrimination. Such approaches at least do no harm. However, they often are less than effective because they fail to respond to gender-specific needs. EXAMPLE: Prevention messages that are not targeted to any one sex, such as “be faithful,” make no distinction between the needs of women and men.
___C: Program approaches or activities recognize and respond to the different needs and constraints of individuals based on their gender and sexuality. These activities significantly improve women’s (or men’s) access to protection, treatment, or care. However, they do not alter the balance of power between men and women; and they do little to change the larger contextual issues that lie at the root of gender inequities. EXAMPLE: Efforts to integrate screening for domestic violence with women’s annual checkups helps women access such services without fear of stigmatization; however, the needs and roles/responsibilities of males are not addressed, nor are the contextual factors that promote stigma.
___D: Program approaches or activities continuously help men and women examine societal gender expectations, stereotypes, and discrimination, and their impact on male and female health and relationships. EXAMPLE: A life skills training program, addresses healthy eating as well as broader community issues through social change activities that encourage female and male participants to question gender norms related to why they eat, cook or buy foods the way that they do; and encourages them to take responsibility to change their own norms so they can promote healthier eating in the future for themselves and others. Societal level norms are not the focus.
___E: Program approaches or activities pro-actively seek to build equitable social norms and structures in addition to individual gender-equitable behavior. EXAMPLE: An effort that both encourages groups of people to work together at the grass roots level to foster change through examining gender and sexuality and their impact on male and female health and relationships, as well as to reduce violence against women through organizing a network of people and agencies to proactively engage in political debate about the rights of vulnerable women.
PLEASE CHECK ONLY ONE OF THE ABOVE CATEGORIES BEFORE MOVING ON.
Form Approved
OMB No. 0990-
Exp. Date XX/XX/20XX
SECTION V. YOUR BACKGROUND, HEALTH, and SECTOR REPRESENTED
Are you?: ___Female __Male ___Other
Are you Hispanic or Latino/Latina? ___Yes ___No
What is your race? (Check all that apply):
__American Indian or Alaska Native
__Asian
__Black or African American
__Native Hawaiian or Other Pacific Islander
__White
How long have you worked in this community (i.e., the general vicinity or area in which the coalition is focused/target communities)? If you do not live in the specific area, but work there or have another connection which attaches you to the community, what is the length of time to which we are referring?
____years ____months
How would you rate your health today?
__1—Excellent 2—Very Good 3—Good 4—Fair 5—Poor
Sector you represent (check all that apply)
__Public health departments
__Schools/Academia
__Other governmental agencies (e.g., human and social services, housing, economic development, public safety) or elected officials
__Grassroots organizations
__Organizations that serve underrepresented racial/ethnic groups or English as a Second Language participants
__Healthcare settings
__Wellness (sports club, spa, trainer, prevention specialists
__Affiliate of national health organization
__Communications and marketing
__Foundations and philanthropic organizations
__Foundations and philanthropic organizations
__Insurance carrier/health plan
__Citizen/resident, no affiliation
__Business/industry/private entity
__Other (please specify): ______________________
Please indicate for each of the following the response that best reflects what you know about the topic.
I am knowledgeable about the difference between “sex” and “gender.”
1—Not at all 2--Somewhat 3-Very
I am knowledgeable about the significant differences between men’s and women’s health.
Form Approved
OMB No. 0990-
Exp. Date XX/XX/20XX
1—Not at all 2--Somewhat 3-Very
Comments/Suggestions
Do you have any comments about or suggestions for improvement of programming and services to improve women and girls’ health in your community?
___NO (skip to submit)
___YES (please elaborate)
Thank you for your participation.
The Office on Women’s Health will compile the results of this survey and send the findings for our community to the Coalition’s Project Director to share with our community.
SUBMIT
Key Persons, Coalition
Members, and Community Leaders Online Survey
| File Type | application/msword |
| Author | ray |
| Last Modified By | Windows User |
| File Modified | 2015-10-29 |
| File Created | 2015-10-29 |