Form 0920-0840 Eligibility Screener - Prenatal Care Providers

Form Approved

OMB No. 0920-0840

Expiration Date: 01/31/2019

2018 Congenital Syphilis Study

Eligibility Screener Prenatal Care Providers

Attachment #a

Public reporting burden of this collection of information is estimated to average 10 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 NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-0840)

Screening Form: Prenatal Care Providers

Hello, my name is _____________ and I am a research assistant. On behalf of the University of California / Tulane University, I am helping to implement a study with health care professionals who provide antenatal care to pregnant women. We aim to learn about current antenatal care practices in regions of the United States with high prevalence of sexually transmitted infections (STIs) like syphilis. Over the past 5 years there has been an increase in the rate of congenital syphilis cases in Kern County / East Baton Rouge Parish. The purpose of this study is to develop guidelines for health care users to effectively communicate with their patients at highest risk for syphilis infection/transmission so as to offer the best prevention and treatment services.

Some of the antenatal care professionals we speak with today will be invited to participate in a telephone or in-person interview that will pay an honorarium of $50, for about 60 minutes as a token of appreciation for your participation. The interviews will be scheduled during the weeks of _____________ 2018. Are you interested in participating, and do you have some availability in that timeframe?

Yes  Continue

No  Exit script

May I ask you a few questions to see if you qualify?

1. Have you participated in any focus groups or been interviewed for any opinion-research studies about syphilis or congenital syphilis in the past 6 months?

   1. No  Continue

   2. Yes  Exit script

2. What is your current position?

   1. Obstetrician/gynecologist (OB/GYN)

   2. Family practice doctor (family physician)

   3. Maternal-fetal medicine (MFM) specialist

   4. Certified nurse-midwife (CNM)

   5. Family nurse practitioner (FNPs)

   6. Women's health nurse practitioner (WHNP)

3. On average, how many hours per week do you currently spend in direct antenatal patient care?

   1. 40 or more  Continue

   2. 20-39  Continue

   3. Less than 20  exit script

4. Which best describes the setting in which you practice? [Recruit a mix]

   1. Solo practice

   2. Single-specialty group practice

   3. Multi-specialty group practice

   4. HMO or Managed Care Organization (MCO)

   5. Ambulatory care center of hospital/medical center

   6. Community or public health clinic

   7. University or college student health facility

   8. Urgent care facility

   9. Government health facility (e.g., Veterans Administration)

   10. Other (please specify): ____________________________

5. How many years have you been in practice?

   1. More than 5 years - Recruit at least 4 per patient racial/ethnic segment  Continue

   2. 1 to 5 years - Recruit no more than 5 per patient racial/ethnic segment  Continue

   3. Less than 1 year  Thank and terminate

6. Have you worked in [Kern County/ East Baton Rouge Parish] for at least 12 months?

   1. Yes  Continue

   2. No  Exit script

7. We’re interested in talking to primary care professionals who serve patients from a range of racial and ethnic backgrounds. Approximately what percent of your patients are from the following groups (Prompt for each racial/ ethnic group below):

   1. White or Caucasian

   2. Black or African American

   3. Hispanic or Latino

   4. Native American

   5. Asian American

If patients are primarily Hispanic/Latino or Asian American:

What is the primary language most of your patients speak? ________________

8. Would you describe the majority of your patients as being in a:

   1. Lower socio-economic level

   2. Middle socio-economic level

   3. Higher socio-economic level

9. On average, how many female patients with a diagnosis of syphilis do you see each quarter (i.e., in a 3-month period)? This may be a diagnosis based on results from a blood test or from a test of fluid from a syphilis sore, or a combination of these.

   1. More than 10 patients Continue

   2. 5 to 10 Continue

   3. Fewer than 5 Continue

   4. None Thank and terminate;

   5. Don’t know Thank and terminate

10. Approximately how many of the patients that you see are uninsured or publicly insured (such as through Medicaid or the Affordable Care Act / ObamaCare)? [Prompted]

    1. A few

    2. Some

    3. About half

    4. Most

    5. All

    6. Don’t know

11. Now I’d like to tell you the types of antenatal care providers we’re seeking for this study. Can you suggest any colleagues who might fit these criteria? If the respondent qualifies for the study, specify that referrals need to be someone outside their office or practice. If the respondent does not qualify, referrals to colleagues from the same office or practice are fine.

Read criteria:

1. Obstetrician/gynecologist, family practice doctor, maternal-fetal medicine specialist, certified nurse-midwife, family nurse practitioner, women's health nurse practitioner

2. Spends 20 hours or more each week in direct patient care

3. Has been in practice at least one year, and ideally five years or more

4. Has been working for at least one year in Kern County / East Baton Rouge Parish

5. Sees at least one patient every 3 months with a syphilis diagnosis

Record contact information for any referrals.

If eligible:

Great, thanks for answering my questions! Based on what you told me, it looks like you are eligible to participate in our study! For next steps, we just need to schedule you for a phone / in-person interview. The interview will last about 60 minutes, and you will be compensated with a $50 gift card for your time. The interview will take place outside of your normal business hours, at a time convenient to you. Would you like to participate?

Yes  Continue to schedule participant

No  Ok, thank you for your time.

If NOT eligible:

Thank you so much for your time. Based on your responses, it appears that you are not eligible for the study we are conducting. Thank you for your time.