CT Barriers to Care Survey

Form Approved

OMB No. 0920-New

Expiration Date: XX/XX/XXXX

Cooperative Re-Engagement Controlled Trial (CoRECT)

Attachment #6

Connecticut Barriers to Care Survey

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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-New)

Attachment 6. Connecticut Barriers to Care Survey

Project CoRECT__________________________________

Barriers to Care

Interview Script: People can have many different types of problems getting their HIV medical care. Think of reasons why you have not received the medical care you needed or care that was recommend to you. Please indicate “AGREE” or “DISAGREE” for all of the following reaons for why you may not have gotten the needed medical care in the past month. In the past month”

*Interviewer note: DO NOT READ the response option REFUSED to the participant. Only mark this response if a person chooses to skip a questions.

Attitudes/Perceptions about HIV and Health

1. You didn’t really care about your health	Agree(1)	Disagree(2)	Don’t Know(7)	Decline(8)	Missing(9)
2. You didn’t feel sick	Agree(1)	Disagree(2)	Don’t Know(7)	Decline(8)	Missing(9)
3. You were too sick	Agree(1)	Disagree(2)	Don’t Know(7)	Decline(8)	Missing(9)
4. You didn’t want to go	Agree(1)	Disagree(2)	Don’t Know(7)	Decline(8)	Missing(9)

Challenges with the Medical Facility

5. The clinic’s hours of operation didn’t match your hours	Agree(1)	Disagree(2)	Don’t Know(7)	Decline(8)	Missing(9)
6. You were treated poorly at a clinic in the past	Agree(1)	Disagree(2)	Don’t Know(7)	Decline(8)	Missing(9)

Challenges with the Medical Provider

7. You couldn’t find a provider that could speak with you in your native language	Agree(1)	Disagree(2)	Don’t Know(7)	Decline(8)	Missing(9)
8. You don’t trust doctors	Agree(1)	Disagree(2)	Don’t Know(7)	Decline(8)	Missing(9)

Time Management and Organization

9. You couldn’t take time off of work or school	Agree(1)	Disagree(2)	Don’t Know(7)	Decline(8)	Missing(9)
10. You forgot	Agree(1)	Disagree(2)	Don’t Know(7)	Decline(8)	Missing(9)
11. You do not like to make appointments too far in advance	Agree(1)	Disagree(2)	Don’t Know(7)	Decline(8)	Missing(9)

Health Insurance and Access to Medical Care

12. You didn’t have health insurance	Agree(1)	Disagree(2)	Don’t Know(7)	Decline(8)	Missing(9)
13. You weren’t sure where to go to get medical care	Agree(1)	Disagree(2)	Don’t Know(7)	Decline(8)	Missing(9)

Social and Supportive Services

CHILDCARE 14. You didn’t have child care	Agree(1)	Disagree(2)	Don’t Know(7)	Decline(8)	Missing(9)
TRANSPORTATION 15. You didn’t have transportation to medical care	Agree(1)	Disagree(2)	Don’t Know(7)	Decline(8)	Missing(9)
FINANCIAL CHALLENGES 16. You couldn’t pay for medical care	Agree(1)	Disagree(2)	Don’t Know(7)	Decline(8)	Missing(9)
STIGMA 17. You didn’t want to be seen at a clinic	Agree(1)	Disagree(2)	Don’t Know(7)	Decline(8)	Missing(9)
MEDICATION ADHERENCE 18. You didn’t want your health care provider to be mad at you for not taking your meds	Agree(1)	Disagree(2)	Don’t Know(7)	Decline(8)	Missing(9)
MENTAL HEALTH 19. You were too depressed	Agree(1)	Disagree(2)	Don’t Know(7)	Decline(8)	Missing(9)
SUBSTANCE USE 20. You were too drunk or high	Agree(1)	Disagree(2)	Don’t Know(7)	Decline(8)	Missing(9)
OTHER REASON 21. Any other reasons you have not received HIV medical care? Specify:	Agree(1)	Disagree(2)	Don’t Know(7)	Decline(8)	Missing(9)

Notes