Contraceptive Assessment For Puerto Rico During Zika (ca

Form Approved

OMB Control No. 0920-1114

Expiration date: 11/30/2016

CONTRACEPTIVE ASSESSMENT FOR PUERTO RICO DURING ZIKA (CAPRZ) QUESTIONNAIRE

Script: HELLO, I am calling for the Puerto Rico Department of Health. My name is (name) . We are gathering information about the health of Puerto Rico residents. This project is conducted by the Health Department with assistance from the Centers for Disease Control and Prevention. Your telephone number has been chosen randomly. I would like to ask some questions about contraception and health practices related to the Zika virus in Puerto Rico.

S1. Is this (phone number) ?

Yes

No-->[Confirm phone number] AND SAY: “Thank you very much, but I seem to have dialed the wrong number. It’s possible that your number may be called at a later time. END INTERVIEW

Participation in this survey is voluntary. You may skip any questions and you may end your participation at any time. We will not ask you for any personally identifying information, such as your name or address. No personal identifiers will be used in the reporting of data from this survey. The survey normally takes about 10 minutes to complete. We greatly appreciate your time and cooperation. First, I’d like to ask you a few questions to see if you qualify for this survey.

Consent & screening

S2. Are you willing to participate in this survey?

Yes

No--> END INTERVIEW AND THANK HIM/HER FOR THEIR TIME.

S3. Is this a good time to talk with you?

Yes

Nosay “Thank you very much. We will call you back at a more convenient time.” STOP

(SET APPOINTMENT IF POSSIBLE)

S4 Is this a cell phone?

Yes

No---> END INTERVIEW. Thank him/her and say that we are only interviewing on cell phones.

Demographic screening questions

1. I’d like to know if you are male or female:

1 MaleEND INTERVIEW. Thank him and inform him that only females are being interviewed

2 Female

7 Don’t Know/Not sure  END INTERVIEW. THANK THEM AND SAY THAT ONLY FEMALES ARE BEING INTERVIEWED

9 Refused to answer  END INTERVIEW. THANK THEM AND SAY THAT ONLY FEMALES ARE BEING INTERVIEWED

2. How old are you?

ENTER AGE AT LAST BIRTHDAY ___ ___ YEARS

IF RESPONDENT IS NOT 18 To 49 YEARS OF AGE, END INTERVIEW. THANK HER AND SAY THAT ONLY WOMEN AGES 18 TO 49 ARE BEING INTERVIEWED.

3. Do you currently live in Puerto Rico?

1 Yes

2 NoEND INTERVIEW. Thank her and say that only residents of Puerto Rico are being interviewed.

Demographics

4. In which municipality do you live?

Enter FIPS code _______

5. Are you Hispanic or Latina, or of Spanish origin?

1 Yes

2 No

7 Don’t Know/Not sure

9 Refused to answer

6. Where were you born? (SELECT FROM LIST – DO NOT READ)

1 Puerto Rico

2 United States (not Puerto Rico)

3 Cuba

4 Dominican Republic

5 Mexico

6 Other Latin America/Caribbean

7 Other not Latin America/Caribbean

77 Don’t Know/Not sure

99 Refused to answer

7. What is the highest grade or year of school you completed? (DO NOT READ CHOICES)

1 Never attended school or only attended kindergarten

2 Grades 1 through 8 (Elementary)

3 Grades 9 through 11 (Some high school)

4 Grade 12 or GED (High school graduate)

5 College 1 year to 3 years (Some college or technical school)

6 College 4 years or more (College graduate)

7 Don’t know

9 Refused

8. Are you still attending school?

1 Yes

2 No

7 Don’t know/Not sure

9 Refused

9. What is the primary source of your health care coverage? (READ CHOICES)

1 A plan purchased through an employer or union (includes plans purchased through another person’s employer)

2 A plan that you or a family member buys on their own

3 Medicaid or other state or federal program

4 TRICARE

5 Some other source

6 None

7 Don’t Know/Not sure

9 Refused

10. Are you (READ CHOICES 1-7, DO NOT READ 77/99):

1 Married to a man

2 Not married, but living with, or in a long-term relationship with a man

3 Widowed

4 Divorced or annulled

5 Separated

6 Married, living with, or in a long-term relationship with a woman

7 Never married and not in a long-term relationship

77 Don’t Know/Not sure

99 Refused

Zika Knowledge

11. How worried are you about getting infected with the Zika virus? (READ CHOICES 1-6, DO NOT READ 7/9, AND SELECT ONE)

1 Very worried

2 Somewhat worried

3 A little worried

4 Not at all worried

5 Have already had Zika virus

6 Have never heard of Zika virus

7 Don’t Know/Not sure

9 Refused

12A. At any time, has a doctor, nurse, or other healthcare worker talked to you about Zika?

1 Yes

2 No  GO TO QUESTION 13

7 Don’t Know/Not sure  GO TO QUESTION 13

9 Refused  GO TO QUESTION 13

12B. Did you ask him/her about Zika before that discussion

1 Yes

2 No

7 Don’t Know/Not sure

9 Refused

13. Has a doctor, nurse, or other healthcare worker offered you a test for Zika?

1 Yes

2 No

7 Don’t Know/Not sure

9 Refused

13. Have you been tested for Zika virus?

1 Yes

2 No

7 Don’t Know/Not sure

9 Refused

13. Has a doctor, nurse, or other healthcare worker told you that you had Zika virus infection?

1 Yes

2 No

7 Don’t Know/Not sure

9 Refused

13. From what source have you received the most information about Zika virus? (DO NOT READ CHOICES AND SELECT ONE, PROBE IF NECESSARY)

1 Healthcare worker (for example, a family doctor, OB/GYN, midwife, nurse, other medical professionals)

2 Family or friends

3 The Centers for Disease Control and Prevention’s (CDC)

4 Health Department (either Puerto Rico Department or local)

5 Television

6 Radio

7 Social network sites like Facebook

8 Newspaper

9 Other website

10 Some other source

11 Have not received information

77 Don’t Know/Not sure

99 Refused to answer

13. What source would you trust the most for receiving information about Zika virus? (READ CHOICES 1-9, DO NOT READ CHOICES 9, 10, OR 77, AND SELECT ONE)

READ:

1 Healthcare worker (for example, a family doctor, OB/GYN, midwife, nurse, other medical professionals)

2 Family or friends

3 The Centers for Disease Control and Prevention’s (CDC)

4 Health Department (either Puerto Rico Department or local)

5 Television

6 Radio

7 Social network sites like Facebook

8 Newspaper

9 Other website

Don’t Read:

10 Some other source

11 Have not received information

77 Don’t Know/Not sure

99 Refused to answer

13. Currently, do you do any of the following to avoid mosquito bites in your home? (READ EACH ITEM)

Yes No

A Always use screens on open doors  

B Always use screens on open windows  

INTERVIEWER NOTE: ANSWER Q18B AND IF 18A=1 (YES) AND 18B=1 (YES) THEN GO TO 18D

C Keep unscreened doors and windows closed  

D Use fans or air conditioning  

E At least once a week, eliminate standing water from my house and yard  

F Always sleep under a mosquito bed net  

18F. How often do you sleep under a mosquito bed net? (READ CHOICES):

1 Every night

2 Most nights

3 Some nights

4 Rarely

5 Never

7 Don’t Know/Not sure

9 Refused to answer

19. How often do you use mosquito repellent on your skin when you go outside? (READ CHOICES AND SELECT ONE)

1 Every day

2 Most days

3 Some days

4 Rarely

5 NeverGO TO 21

7 Don’t Know/Not sure GO TO 21

9 Refused to answer GO TO 21

19. On days when you use mosquito repellent on your skin, do you usually apply it more than once?

1 Yes

2 No

7 Don’t Know/Not sure

9 Refused to answer

INTERVIEWER NOTE: ANSWER Q20 AND IF QUESTION 19=1, THEN GO TO QUESTION 22

19. When you do not wear mosquito repellent, is it because:

YES NO

1. You do not like the way it smells?  

2. You do not like the way it makes my skin feel?  

3. You worry about the chemicals in the repellent being harmful?  

4. Mosquito repellent is too expensive?  

5. You forget to apply it?  

22. During the past month, how often did you wear long sleeves and long pants when you went outside? (READ CHOICES AND SELECT ONE)

1 Every dayGO TO 24A

2 Most days

3 Some days

4 Rarely

5 Never

7 Don’t Know/Not sure

9. Refused to answer

23. When you did not wear long sleeves and long pants what was your main reason? (DO NOT READ ANSWERS; ENTER ONE REASON ONLY)

1 I did not have (enough/many) clothes with long sleeves or long pants

2 It was too hot to wear long sleeves or long pants

3 I don’t like to wear long sleeves or long pants

7 Don’t Know/Not sure

9 Refused to answer

24. During the last 3 months, did you receive any of the following services for mosquito control?

Yes No

A. Professional indoor spraying of your house?  

B. Professional outdoor spraying around your house and yard?  

C. Application of larvicides around the outside of your house?  

Now we are going to ask you some questions about reproductive health. Please remember that all your answers are confidential.

25. Are you pregnant?

1 Yes

2 No

7 Don’t Know/Not sure

9 Refused to answer

25. About how long has it been since you last had sexual intercourse with a man? (DO NOT READ CHOICES)

1 Less than 3 months

2 3-6 months GO TO Q30

3 7-12 months GO TO Q30

4 More than a year GO TO Q30

5 Never had sexual intercourse with a man GO TO Q30

7 Don’t Know/Not sure GO TO Q30

9 Refuse to answerGO TO Q30

25. When you had sex during the last 3 months, how often did you and your partner use a condom? Was it (READ CHOICES 1-4, DO NOT READ 7/9, AND SELECT ONE):

1 Every time you had sex?

2 Most of the times you had sex?

3 Some of the times you had sex?

4 Not at all?GO TO Q29

7 Don’t Know/Not sureGO TO Q30

9 Refused to answerGO TO Q30

25. Where did you or your partner get your condoms? (IF MORE THAN ONE SOURCE, ASK WHERE MOST OFTEN GOT THEM) (DO NOT READ CHOICES)

(IF RESPONDENT GIVES NAME OF SPECIFIC CLINIC OR FACILITY, PROBE TO DETERMINE WHETHER IT WAS A PUBLIC OR PRIVATE FACILITY)

1 Pharmacy

2 Other store or shop (gas station)

3 Public health clinic/facility

4 Private doctor or clinic

5 Visiting nurse

6 Bar/Club/Restaurant

7 Somewhere else

77 Don’t Know/Not sure

99 Refused to answer

Interviewer Note: Ask After Q28 and IF Q27 = 1 (USE CONDOMS EVERY TIME HAS SEX) GO TO Q30

25. What was your most important reason for not using condoms every time you had sex during the last 3 months? (DO NOT READ CHOICES; SELECT ONE REASON)

1 Already using another contraceptive method

2 Didn’t think was going to have sex

3 Didn’t think about it

4 Wanted to get pregnant/ Didn’t mind if got pregnant

5 In a committed relationship

6 Didn’t want to use condoms

7 Partner didn’t want to use condoms

8 Couldn’t pay for condoms

9 Had a problem getting condoms when needed/ No condoms available

10 Religious reasons

11 Menopause/ InfertileGO TO Q38

12 Had a hysterectomyGO TO Q38

13 Had tubes tied (sterilization

14 Partner had a vasectomy (sterilization)

15 Was breastfeeding at the time

16 Recently had a baby/Postpartum

17 Was pregnant

18 Forced to have sex

19 Under the influence of alcohol or drugs

20 Other reason

77 Don’t Know/Not sure

99 Refused to answer

25. How do you feel about having a child now or sometime in the future? Would you say:

(READ CHOICES)

1 You don’t want to have one/another

2 You want to have one, less than 12 months from now

3 You want to have one, between 1 to 2 years from now

4 You want to have one, between 2 and 5 years from now

5 You want to have one, at least 5 years from now

6 You want to have one, but not sure when

7 Not sure if want to have any/another

9 Refused to answer

Interviewer Note: Ask Q30 then IF CURRENTLY PREGNANT (Q25 = 1) OR NEVER HAD SEX (Q26=5) GO TO Q36

25. Are you or your male partner doing anything or using anything to keep from getting pregnant? (This includes things like sterilization, vasectomy, an IUD or injections.)

1 Yes

2 No GO TO Q35

7 Don’t Know/Not sure GO TO Q36

9 Refused to answer GO TO Q36

25. What are you or your spouse or partner using or doing to keep you from getting pregnant? (DO NOT READ CHOICES; IF MORE THAN 1 REASON GIVEN, ENTER THE ONE WITH THE LOWEST NUMBER)

1 Female sterilization (tubal ligation, tubes tied, Essure, Adiana)

2 Male sterilization (vasectomy)

3 Contraceptive implant (Nexplanon, Jadelle, Sino Implant, Implanon)

4 Hormonal IUD (for example, Mirena, Skyla, Liletta)

5 Copper-bearing IUD (ParaGard)

6 IUD, type unknown

7 Shots/Injections (for example, Depo-Provera)

8 Birth control pills (daily pills, any kind)

9 Contraceptive patch (Ortho Evra, Xulane)

10 Contraceptive ring (NuvaRing)

11 Male condoms Go to Q36

12 Diaphragm Go to Q36

13 Female condoms Go to Q36

14 Foam, jelly, film, or cream Go to Q36

15 Emergency contraception (morning after pill) Go to Q36

16 Not having sex at certain times (rhythm or natural family planning) Go to Q36

17 Withdrawal (pulling out) Go to Q36

18 Other methodGo to Q36

77 Don’t Know/Not sure

99 Refused to answer

25. Where did you or your partner obtain that method (most recently)?

1 Pharmacy

2 Public hospital

3 Private hospital

4 Public health clinic

5 Private doctor’s office or clinic

6 Visiting nurse

7 Somewhere else

77 Don’t Know/Not sure

99 Refused to answer

25. As best you can remember, since what month and year have you been start using that method of contraception?

Month ___ ___ Year  ___ ___ ___ ___  GO TO QUESTION 36

77/7777 Don’t Know/Not sure GO TO QUESTION 36

99/9999 Refused to answer GO TO QUESTION 36

25. What is the most important reason for not doing anything to keep you from getting pregnant ? (DO NOT READ ANSWERS; ENTER ONE REASON ONLY)

1 Haven’t thought about using anything

2 Don’t care if get pregnant

3 Want to get pregnant

4 Partner objects

5 Don’t like contraception/Worry about side effects

6 Can’t pay for contraception

7 Have a problem getting contraception when needed

8 Religious reasons

9 Menopause

10 Have not gotten pregnant in over 2 years without using contraception

11 Had a hysterectomy

12 Don’t think I can get pregnant

13 Was breastfeeding

14 Recently had a baby/Postpartum

15 No male partner/not sexually activity

16 Other reason

77 Don’t Know/Not sure

99 Refused to answer

25. In the last 12 months, was there a time when you wanted to see a provider for contraception but could not for any reason?

1 Yes

2 No

7 Don’t Know/Not sure

9 Refused to answer

25. Have you ever received contraceptives services as part of the Zika Contraception Access Network

(Z-CAN) Project?

1 Yes

2 No

7 Don’t Know/Not sure

9 Refused to answer

Interviewer Note: Ask Q37 then If Currently Pregnant (Q25=1) GO TO Q41

25. Have you ever been pregnant?

1 Yes

2 No GO TO INSTRUCTIONS BEFORE Q45

7 Don’t Know/Not sureGO TO INSTRUCTIONS BEFORE Q45

9 Refused to answer GO TO INSTRUCTIONS BEFORE Q45

25. In what month and year did your most recent pregnancy end?

MONTH: __ __ YEAR: __ __ __ __

77/7777 Don’t Know/Not sure

99/9999 Refused to answer

25. How did your most recent pregnancy end? (READ CHOICES 1-5, DO NOT READ 7/9, AND SELECT ONE)

1 Live birth

2 Stillbirth (after 20 weeks gestation)

3 Miscarriage (before 20 weeks gestation, also called spontaneous abortion)

4 Ectopic pregnancy

5 Induced Abortion

7 Don’t know/Not sure

9 Refused

25. How many children have you given birth to who are still alive, including any who do not live with you?

___ ___ Children

77 Don’t know/Not sure

88 None

99 Refused

IF RESPONDENT’S LAST PREGNANCY ENDED BEFORE 2011 (Q39 YEAR < 2011), AND SHE IS NOT CURRENTLY PREGNANT (Q25 NOT EQUAL TO 1) GO TO INSTRUCTIONS BEFORE Q45

Circumstances of Pregnancy

IF RESPONDENT IS CURRENTLY PREGNANT, SAY: The next questions that ask about your circumstances and feelings around the time you became pregnant for your current pregnancy. Please think of your current pregnancy when answering the next questions.

IF RESPONDENT IS NOT CURRENTLY PREGNANT, SAY: The next questions that ask about your circumstances and feelings around the time you became pregnant. Please think of your most recent pregnancy when answering the next questions.

25. Were you or your male partner doing anything or using anything to keep from getting pregnant? (This includes things like sterilization, vasectomy, an IUD or injections.)

1 Yes

2 No GO TO Q44

7 Don’t know/Not sure GO TO Q44

9 Refused GO TO Q44

25. What did you or your spouse or partner use or do to keep you from getting pregnant? (DO NOT READ CHOICES; IF MORE THAN 1 REASON GIVEN, ENTER THE ONE WITH THE LOWEST NUMBER)

1 Female sterilization (tubal ligation, tubes tied, Essure, Adiana)

2 Male sterilization (vasectomy)

3 Contraceptive implant (Nexplanon, Jadelle, Sino Implant, Implanon)

4 Hormonal IUD (for example, Mirena, Skyla, Liletta)

5 Copper-bearing IUD (ParaGard)

6 IUD, type unknown

7 Shots/Injections (for example, Depo-Provera)

8 Birth control pills (daily pills, any kind)

9 Contraceptive patch (Ortho Evra, Xulane)

10 Contraceptive ring (NuvaRing)

11 Male condoms

12 Diaphragm

13 Female condoms

14 Foam, jelly, film, or cream

15 Emergency contraception (morning after pill)

16 Not having sex at certain times (rhythm or natural family planning)

17 Withdrawal (pulling out)

18 Other method

77 Don’t know/Not sure

99 Refused

25. Thinking back to just before you got pregnant, how did you feel about getting pregnant? (READ CHOICES AND SELECT ONE)

1 I wanted to get pregnant later

2 I wanted to get pregnant sooner

3 I wanted to get pregnant then

4 I didn’t want to get pregnant then or at any time in the future

5 I wasn’t sure what I wanted

7 Don’t know/Not sure

9 Refused

Zika-related attitudes and behaviors

IF PERMANENTLY UNABLE TO BECOME PREGNANT (HAD A HYSTERECTOMY, MENOPAUSAL, OR INFERTILE) END QUESTIONNAIRE: (Q29=11 OR 12) OR (Q35=9, 10, OR 11)

25. How worried are you about having a child with microcephaly or another birth defect linked to Zika virus? (READ CHOICES 1-4, DO NOT READ 5/7/9, AND SELECT ONE)

1 Very worried

2 Somewhat worried

3 A little worried

4 Not at all worried

5 I have never heard of a link between Zika and birth defects

7 Don’t know/Not sure

9 Refused to answer

25. Have you changed your plans about whether or when to have (more) children because of the Zika virus outbreak in Puerto Rico?

1 Yes

2 NoGO TO Q48

7 Don’t know/Not Sure GO TO Q48

9 Refused to answerGO TO Q48

25. How have you changed your plans? Have you: (READ CHOICES 1-3 AND SELECT ONE)

1 Decided to wait longer to become pregnant

2 Decided to have no more children

3 Decided not to get pregnant soon, but have not made long-term plans yet

4 Other

7 Don’t know/Not Sure

9 Refused to answer

25. Have you changed your contraceptive use because of the Zika virus outbreak? (DO NOT READ CHOICES; SELECT ONE)

1 Yes: Started using a method

2 Yes: Switched to a more effective method

3 Yes: More consistent in using contraceptive method

4 Yes: Using condoms in addition to my usual contraceptive method

5 Yes: Other

6 No change

7 Don’t know/ Not sure

9 Refused to answer

CLOSING STATEMENT

That was my last question. Everyone’s answers will be combined to help us provide information about contraception and health practices related to the Zika virus in Puerto Rico. Thank you very much for your time and cooperation

Public reporting burden of this collection of information is estimated to average 15 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: PRA 0920-1114