Date: ____________ Initials: _______________Continuation Date: _________Time (mn):________
Form Approved
OMB No. 0920-1118
Expires 12/31/2016
ATTACHMENT C: Initial Telephone Interview
Hello, [respondent name], my name is __________ and I am from the Puerto Rico Department of Health OR the Centers for Disease Control and Prevention.
The purpose of this call is to assess the different services that ar offered to pregnant women to protect themselves and their babies from Zika. Do you have time to answer some questions about what you are doing and what assistance you might have received? This will help us provide better services and support for you and your baby, and pregnant women in Puerto Rico in general.
No
Yes, [If yes, are you over 18 years of age]
Are you currently pregnant?
No (end call)
Yes (continue)
SECTION 1. Introduction
Great! Thank you for your willingness to share your opinions with me. Your opinions will help us improve the types of services we can offer pregnant women, like yourself. I have just a few questions that will take less than 20 minutes. If we get disconnected, I will call you back.
Before I begin I want to go over a couple of items:
This interview is voluntary. You can decline to answer any question and you can end our conversation at any time
There are no right or wrong answers. I am interested in your opinion. If you don’t understand the question, feel free to let me know and I can ask it another way. This is not a test, so feel free to say you don’t know or don’t have an opinion to offer and “I don’t know“ is a perfectly acceptable response to any question I ask you.
The information you provide today will not be shared with anyone except those involved in this project. It’s important to know that the questions I’m about to ask you will not affect your eligibility for WIC services in any way. Our reports will include the responses of ALL the women who talk with us so that you can provide honest answers without worrying that your answers will hurt you in any way. Your answers cannot be linked back to you.
Do you have any questions before we begin?
Public reporting burden of this collection of information is estimated to average 20 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 (0920-1118).
What have you heard about Zika? (Do not read, tick all mentioned)
Pregnant women should try not to get it
It causes microcephaly or brain defects in babies
People get it from mosquitoes, so should avoid getting bitten
It can be transmitted by sex from a man to a woman
People in Puerto Rico are getting infected with Zika – the virus is here
Most people who have it, don’t know it
It causes fever, rash, and conjunctivitis
There is no treatment for Zika
There is no vaccine for Zika
It can be life-threatening – can cause paralysis, GBS
Other, please specify:
Refused [DO NOT READ]
In the past month, how often have you and your family members and friends talked about Zika?
Not at all
Only once or twice
Sometimes
Often
Every day
Refused [DO NOT READ]
How concerned are you about Zika virus for yourself and your baby?
Not at all concerned
Slightly concerned
Somewhat concerned
Moderately concerned
Extremely concerned
Refused [DO NOT READ]
In your opinion, how likely do you think it is that you will be infected with Zika virus during your pregnancy (or while you are pregnant)?
Extremely unlikely
Unlikely
Neutral - Neither unlikely nor likely
Likely
Extremely likely
Refused [DO NOT READ]
And Why? [WRITE ANSWER TO WHY?]
____________________________________________________________________________________________________________________________________________________________
How confident are you in your ability to protect yourself from getting infected with Zika virus during your pregnancy?
Not confident at all
Somewhat unconfident
Neutral - Neither unconfident nor confident
Confident
Very confident
Refused [DO NOT READ]
And Why? [WRITE ANSWER TO WHY?]
____________________________________________________________________________________________________________________________________________________________
What actions have you taken to protect yourself from getting infected with the Zika virus since you found out you were pregnant? (Do not read, tick all mentioned)
Used mosquito net at night
Used mosquito net during the day
Used mosquito repellent or spray on your body
Worn clothes that cover my arms and legs
Used mosquito coil/light fires to keep mosquitoes away
Used a condom/had my partner use a condom in all sexual relations
Abstained from sexual intercourse
Cleaned/scrubbed water source/storage unit/water container(s)
Put cover(s) over the water source/storage unit/water container(s)
Removed accumulated water
Sprayed or fumigated inside my home
Sprayed or fumigated outside of my home
Used larvicides (like mosquito dunks)
Put screens on windows and doors
Cleaned household environment
Drank clean water
Washed I clean water
Prayed to God
No answer
Other, please specify: __________________________________________
Refused [DO NOT READ]
Have you made any changes to your routine since learning more about Zika virus and the risk to your pregnancy?
Yes, what? (Capture verbatim responses)
No, why? (Capture verbatim responses)
Refused [DO NOT READ]
SECTION 2. Communication/WIC Education/CDC Foundation campaign exposures
Are you seeing, hearing, or reading messages about how to prevent Zika?
Yes
Where are you hearing messages on how to prevent Zika? (Do not read, tick all mentioned)
Doctor
WIC
Family & friends
Community meetings/gatherings
TV public service announcements
TV news
Radio news
Printed news (newspapers)
Posters
Billboards
Internet or world wide web
Social media
Other, please specify: _______________________________
No
Refused [DO NOT READ]
Have you been oriented at WIC about Zika?
Yes
No
Don’t know/not sure [DO NOT READ]
Refused [DO NOT READ]
Have you received educational materials (handouts, written information) about Zika from WIC?
Yes
No
Don’t know/not sure [DO NOT READ]
Refused [DO NOT READ]
In the past month, do you remember seeing, hearing, or reading any TV, radio, newspaper, or online advertising about [a FAKE campaign name- “Musicians against Zika”]?
Yes
No
Don’t know/not sure [DO NOT READ]
Refused [DO NOT READ]
In the past month, do you remember seeing, hearing, or reading any TV, radio, newspaper, or online advertising about [CDC Foundation campaign name]?
Yes
No
Don’t know/Not sure [DO NOT READ]
Refused [DO NOT READ]
Now, I am going to describe an ad you may or may not have seen on TV. You may or may not have seen the following ad because it is NOT running in all parts of Puerto Rico. But in the past month, have you happened to have seen an ad that shows [INSERT ad description of CDC Foundation campaign].
Yes
No
Don’t know/Not sure [DO NOT READ]
Refused [DO NOT READ]
Now I’m going to read a list of a few types of communication you may or may not have heard about. Which of the following have you seen or heard about? [REPEAT as necessary for other types of communication]
Message |
Yes |
No |
Don’t know/not sure |
Refused |
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SECTION 3. Questions about Zika Prevention Kits
Have you heard about Zika Prevention Kits?
Yes, what have you heard? (Capture verbatim response. If there description closely resembles the description below, then go directly to question 16.
____________________________________________________________________________________________________________________________________________________________________
No (Read statement below and proceed to question 16)
Refused
Description: The Zika Prevention Kit is a tote bag that contains educational information from the Puerto Rico Health Department and the Centers for Disease Control and Prevention about how to prevent Zika infection while you are pregnant along with items that could help prevent Zika virus infection. Items in the kit include: a mosquito bed net, mosquito repellent, condoms, and some include mosquito dunks (larvicide) and thermometers.
Do you know where you can get a Zika Prevention Kit that is free (or that does not cost you anything)?
Yes
No
Refused
Have you been offered a Zika Prevention Kit?
Yes
From who or what organization?
WIC
My doctor
Other
No
Refused [DO NOT READ]
Have you received a Zika Prevention Kit
Yes
Who gave you your Zika Prevention Kit
WIC
My doctor
Other
No, skip to question 29
Refused [DO NOT READ]
What color was the tote bag?
White
Blue
Green
Other, please specify:
Refused
20. What items were included in the kit? (Do not read, tick all mentioned)
Repellent
Bed net
Mosquito dunks
Condom(s)
Thermometer
Educational materials
Other, please specify:
Don’t know, didn’t open it [SKIP TO QUESTION 29]
Refused [DO NOT READ]
No, why not?
Refused
Of the items in your Zika Prevention Kit, which one is the most important to you? (mark stated item as ranked 1st) Which is the next most important? (mark stated item as ranked 2nd) Which is the next most important? (mark stated item as ranked 3rd) Which is the least important to you? (mark stated item as ranked least important)
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Importance) |
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Item |
Ranked 1st |
Ranked 2nd |
Ranked 3rd |
Least important |
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Repellent |
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Bed net |
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Mosquito dunks |
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Condoms |
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Thermometer |
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Educational materials |
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Other, specified |
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Refused |
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I am going to read you some statements and after I read the statement, I would like to know if you agree or disagree with the statement.
The instructions that came with the Zika Prevention Kit made it easy to know what to do with all of the items in the Zika Prevention Kit. Would you say that you (strongly disagree, disagree, neither disagree or agree, agree, and strongly agree) with the statement.
Strongly disagree
Disagree
Neither disagree nor agree
Agree
Strongly agree
There were no instructions in the kit
Refused [DO NOT READ]
The Zika Prevention Kit helped me understand the importance of not getting Zika during my pregnancy. Would you say that you (strongly disagree, disagree, neither disagree or agree, agree, and strongly agree) with the statement.
Strongly disagree
Disagree
Neither disagree nor agree
Agree
Strongly agree
Refused [DO NOT READ]
Some of the items in the kit may be items that you already had in your house and used. Others may be items that you didn’t have or have never used before.
BEFORE receiving the kit, when you were pregnant, how often did you use each of the following the items?
How often were you using these items BEFORE receiving the kit? |
Never or Almost Never
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Seldom or Rarely |
Sometimes |
Often |
Usually or most of the time |
Always or Almost always |
Refused |
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AFTER receiving the kit, how often did you use the types of items?
How often are you using these items AFTER receiving the kit? |
Never or Almost Never
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Seldom or Rarely |
Sometimes
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Often |
Usually or most of the time |
Always or Almost always |
Refused |
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Have you used up any of the items that were included in the Zika prevention kit? (or have you needed to replace any items that came in the kit?) Which items?
Yes, which items
Repellent
Condoms
Mosquito dunks (or other larvicide)
Mosquito bed net
No
Don’t know/not sure
Refused [DO NOT READ]
Have you purchased any items to replace the items in the kit that you used up (or needed to replace)?
Yes, which items
Repellent
Condoms
Mosquito dunks (or other larvicide)
Mosquito bed net
No, why not?
Do not have money to buy
Items are too expensive (too costly)
Am embarrassed to buy (e.g., condoms)
Do not feel I need them (they don’t offer protection)
Other, please specify:
Don’t know/not sure
Refused [DO NOT READ]
What other items do you recommend to be included in the Zika Prevention Kit to help pregnant women in Puerto Rico to protect themselves from getting infected with Zika?
I would include the same items that are there now
I don’t know
I would include more (a current item)________________________
I would add…. (new items)
I would do something else entirely (specify)
Don’t know/not sure [DO NOT READ]
Refused [DO NOT READ]
For any items that are not currently included in the Zika Prevention Kit, ask them
why they would put the particular item in the kit? What protection do they think it offers?
SECTION 4. Questions about insecticide services for pregnant women
Have you heard about spraying insecticides inside or outside of homes to protect against mosquitos that carry Zika?
Yes, what have you heard? (Capture verbatim text. If there description closely resembles the description below, then go directly to question 35.
No (Read statement below and proceed to question 35)
Don’t know/not sure [DO NOT READ]
Refused [DO NOT READ]
Description: Indoor residual spraying (IRS) is when specially trained professionals spray insecticide inside of the home in and on the places that mosquitoes like to rest – usually dark and moist places. Examples of places are under tables, behind furniture, under beds and cabinets with sinks, and by dirty laundry. The spraying can be done anytime during the day and usually will kill mosquitoes for about three months. IRS is most effective when most houses in a neighborhood have their homes sprayed.
Have you been offered spraying services for your home? [or Has anyone called you/contacted you to offer you spraying services for free?]
Yes
From who or what organization?
WIC
Department of Health
Other
No (skip to question 38)
Don’t know/not sure [DO NOT READ]
Refused [DO NOT READ]
When services were offered to you, did you want them?
Yes, why (Do not read, tick all mentioned)
Wanted to have fewer mosquitoes in my home
They were free
Want less chance of getting bitten
Don’t want to get Zika
Because my neighbors don’t remove accumulated water
Other, please specify:
No, why not (Do not read, tick all mentioned)
Don’t want chemicals sprayed in my home
I have young children in my home
I have a sick family member
My home does not need spraying (have screens or air conditioning)
My neighbors do a good job of removing accumulated water
Other, please specify:
Don’t know/not sure [DO NOT READ]
Refused [DO NOT READ]
Has an appointment been made for you to receive insecticide spraying in your home? (or has your home been scheduled to receive spraying services?)
Yes
No
Don’t know/not sure [DO NOT READ]
Refused [DO NOT READ]
Have you received spraying services at your home? (or has your home been sprayed already?)
Yes
No
Don’t know/not sure [DO NOT READ]
Refused [DO NOT READ]
How important was it for you to receive insecticide spraying services to prevent Zika while pregnant?
Not at all important
Slightly important
Neutral (not important but not unimportant)
Somewhat important
Very important
Don’t know/not sure [DO NOT READ]
Refused [DO NOT READ]
SECTION 5. Questions about mosquitoes in their environment (environmental stimuli)
In a typical day, how often are you bothered by mosquitoes biting you
Never
Rarely
Sometimes
Often
Always
Don’t Know/not sure [DO NOT READ]
Refused [DO NOT READ]
Where do you spend most of your day on weekdays?
In my home
Inside at work
Outside at work
Outside someone else’s home
Inside someone else’s home
Equal time inside and outside
Other:
Do you have any air conditioning in your home?
No, none
Yes in one room, used at night
Yes, in one room used all the time
Yes in more than one room
Do you spend a lot of time each week in a place that has air-conditioning?
No
Yes
Don’t know/not sure [DO NOT READ]
Refused [DO NOT READ]
Does the home where you live have any screens (escrines, tela metalico, tela mosquitero) on windows that open?
Not on any windows
On some windows
On all windows
Don’t know/not sure [DO NOT READ]
Refused [DO NOT READ]
How about screens on the doors that open outdoors?
None on the doors
On some doors
On all doors
Don’t know/not sure [DO NOT READ]
Refused [DO NOT READ]
Do you have the authority to decide about structural changes (like installing screens) and to fumigate your home inside and outside?
No
Yes
Other, please specify:
Don’t know/not sure [DO NOT READ]
Refused [DO NOT READ]
In what zipcode do you live?
Please specify: ___ ___ ___ ___ ___ -- ___ ___ ___ ___
Don’t know/not sure [DO NOT READ]
Refused [DO NOT READ]
SECTION 6. Questions about Risk Perception of Zika
Do you personally know anyone who has been told by a health professional that they have Zika infection? (Read the options)
No one I know at all
Sort of, people I don’t know well but whom I know have been diagnosed
Yes I know people who have been diagnosed with Zika
Yes, I have a close friend or relative who has been diagnosed
Don’t know/not sure
Refused
Do you personally know anyone who has been told by a health professional she has Zika infection while pregnant? (Read the options)
No one I know at all
Sort of, people I don’t know well but whom I know have been diagnosed
Yes I know people who have been diagnosed with Zika
Yes, I have a close friend or relative who has been diagnosed
Don’t know/not sure
Refused
Have you ever had a Zika test?
Yes
No (Skip to question 47)
Don’t know/not sure [DO NOT READ]
Refused [DO NOT READ]
How long did you have to wait to be told the results of your Zika test?
Less than two weeks
Between two weeks and a month
Over a month but less than two months
Over two months but less than three months
Over three months
Never was told the results of my Zika test
Other, please specify:
Don’t know/not sure [DO NOT READ]
Refused [DO NOT READ]
SECTION 7. Their opinion about what is needed and how to reach pregnant women
What do you think is needed or that needs to happen in order to protect pregnant women from getting infected with the Zika virus? [capture verbatim responses]
In the past week, how often have you used insect repellant?
Never
Seldom or rarely
Sometimes
Often
Usually or most of the time
Always
Refused
Which of the following are actions that someone can take to protect themselves from getting infected with Zika? [Check all that apply. (Read the options)]
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Yes |
No |
Don’t know/Not sure [DO NOT READ] |
Refused [DO NOT READ] |
Use mosquito repellant |
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Drink only clean water |
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Use condoms or not having sex |
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Put screens on windows and doors |
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Wear clothes that cover arms and legs |
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Request to call them back
Can I call you again next month to ask you a few questions about the actions you and the community are taking to protect against Zika?
No
Yes
Is the phone number I used to reach you today, the best number to reach you at?
Yes
No, what number should I call? [Write down phone number]
What is the best time of the day to call you back?
Weekday morning?
Weekday afternoon?
Weekday evening?
Weekend morning?
Weekend afternoon?
Weekend evening?
On behalf of the Puerto Rico Department of Health and the CDC we would like to thank you for your participation in this survey. Your contribution is very important for us. The information you gave us will help us to improve our services. Do you have any questions?
Thank you so much for your participation.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Modified | 0000-00-00 |
| File Created | 2021-01-23 |