Pregnant Woman Enrollment Questionnaire

STUDY ID: ___________________

ZEN COLOMBIA

Pregnant Woman Enrollment Questionnaire

Study site: _______________________________________________________

First, I will start with some questions about you.

1. What is your birthdate? __ __/__ __ __ /__ __ __ __ ₇₇ Don’t know ₈₈ Refused

D D M M M Y Y Y Y

2. What is your ethnicity? (Choose one only).

₁ Mestiza ₂ White ₃ Afrocolombian ₄ Indigenous ₅ Asian ₆ Multi-ethnic ₇ Other

₇₇ Don’t know ₈₈ Refused

3. What is the highest level of education that you have completed?

₁ Less than primary ₂ Primary ₃ Secondary ₄ Technical ₅ University or more

₇₇ Don’t know ₈₈ Refused

4. What is your household’s socioeconomic stratum?

₁ 1 ₂ 2 ₃ 3 ₄ 4 ₅ 5 ₆ 6 ₇₇ Don’t know ₈₈ Refused

5. In the past 3 months, have you traveled to another province or country?

₁ Yes ₀ No ₇₇ Don’t know ₈₈ Refused

If yes: Where did you travel?

a. Place: _________________________ # days: __________

b. Place: _________________________ # days: __________

c. Place: _________________________ # days: __________

The next questions are about mosquito bites.

6. In the past 7 days, how many mosquito bites did you get?

₀ None ₁ Less than 20 ₂ 20 or more, or too many to count

₇₇ Don’t know ₈₈ Refused

7. On average, how many hours per day do you spend outside?

_______ hours/day ₇₇ Don’t know ₈₈ Refused

8. In the past 7 days, how often have you…

	Never	Some of the time	Most of the time	Not applicable	Don’t know	Refused
Worn long pants that covered your legs
Worn shirts or jackets with long sleeves that covered your arms
Worn permethrin-treated clothing
Worn shoes with socks
Used mosquito repellant

9. In the past 7 days, when you were inside your home, how often was the air conditioner running?

₃ Never ₂ Some of the time ₁ Most of the time ₀ I don’t have air conditioning

₇₇ Don’t know ₈₈ Refused

10. Does your home have intact screens on all windows and doors that prevent mosquitos from entering?

₁ Yes ₀ No ₇₇ Don’t know ₈₈ Refused ₁ Not applicable

The next questions are about Zika virus.

11. Do you think it’s possible to get Zika virus in your community?

₁ Yes ₀ No ₇₇ Don’t know ₈₈ Refused

12. Do you know anyone who has had Zika virus?

₁ Yes ₀ No ₇₇ Don’t know ₈₈ Refused

13. How worried are you about getting Zika virus?

₃Very worried

₂ Somewhat worried

₁ Not at all worried

₀ I have already had Zika virus

₇₇ Don’t know

₈₈ Refused

14. Does everybody with Zika virus have symptoms?

₁ Yes ₁ No ₇₇ Don’t know ₈₈ Refused

15. How likely is it that someone can get Zika in the following ways? Say “very likely”, “somewhat likely”, or “impossible” to each statement.

	Very likely	Somewhat likely	Impossible	Don’t know	Refused
Being bitten by an infected mosquito
Having vaginal sex with a man who has Zika without using a condom
Kissing someone who has Zika
Shaking hands with someone who has Zika
An infected person coughs or sneezes on you
From a blood transfusion if the blood has Zika in it
A baby can get Zika before it is born if its mother has Zika during pregnancy

16. How likely is it that the baby of a pregnant woman with Zika will have…? (Say “very likely”, “somewhat likely”, or “impossible” to each statement).

	Very likely	Somewhat likely	Impossible	Don’t know/Refused
Microcephaly (a small sized head)
Other birth defects

17. In the past 3 months, have you had symptoms of Zika virus? Symptoms of Zika virus means being sick with 2 or more of fever, rash, red eyes, and joint pain that are not explained by other causes.

₁ Yes ₀ No ₇₇ Don’t know ₈₈ Refused

If yes: When? _____ / _______

mmm yyyy

18. Has a doctor or healthcare provider ever told you that you might have Zika virus?

₁ Yes ₀ No ₇₇ Don’t know ₈₈ Refused

If yes: When? _____ / _______

mmm yyyy

19. How many adults and children live in your household, including yourself?

________ adults _________ children

20. In the past 3 months, did anyone in your household other than you have symptoms of Zika? Symptoms of Zika means being sick with 2 or more of fever, rash red eyes, or joint pain that are not explained by any other cause.

₁ Yes ₀ No ₇₈ I am the only person in the household

₇₇ Don’t know ₈₈ Refused

If yes: Who was it?

₃ Husband or partner ₂ Your child ₁ Another person in the household

₇₇ Don’t know ₈₈ Refused

21. Has a doctor or healthcare provider ever told anyone in your household, aside from yourself, that they might have Zika virus?

₁ Yes ₀ No ₇₈ I am the only person in the household

₇₇ Don’t know ₈₈ Refused

If yes: Who was it?

₃ Husband or partner ₂ Your child ₁ Another person in the household

₇₇ Don’t know ₈₈ Refused

Next I’ll ask you some questions about your home, community, and environment.

22. Where do you usually get your drinking water? (Select all that apply.)

₈ Public or private water utility

₇ Well

₆ Cistern or tank

₅ Bottled water

₃ Lake, river, or other natural source

₂ Minimo vital de agua potable (“free basic water”)

₁ Water is provided to you, but the source is unknown

₀ Another water source

₇₇ Don’t know

₈₈ Refused

23. In the past 3 months, have you worked at a job? Include jobs in which you don’t have a formal employer, such as selling goods or providing services.

₀ No ₁ Yes ₇₇ Don’t know ₈₈ Refused

If yes: Have any of your jobs in the past 3 months involved:

X-rays	0 No 1 Yes 77 Don’t know 88 Refused
Contact with body fluids	0 No 1 Yes 77 Don’t know 88 Refused
Applying pesticides, insecticides, or rat poison	0 No 1 Yes 77 Don’t know 88 Refused
Battery manufacturing or battery recycling	0 No 1 Yes 77 Don’t know 88 Refused
Electronic waste recycling	0 No 1 Yes 77 Don’t know 88 Refused
Gold mining or gold processing	0 No 1 Yes 77 Don’t know 88 Refused
A job in which you or other people around you use lead	0 No 1 Yes 77 Don’t know 88 Refused
A job in which you or other people around you use mercury	0 No 1 Yes 77 Don’t know 88 Refused

24. In the past 3 months, has anyone in your household other than yourself worked in…

Battery manufacturing or battery recycling	0 No 1 Yes 77 Don’t know 88 Refused 99 No one else in the household
Electronic waste recycling	0 No 1 Yes 77 Don’t know 88 Refused 99 No one else in the household
Gold mining or gold processing	0 No 1 Yes 77 Don’t know 88 Refused 99 No one else in the household
A job in which they or their coworkers use lead	0 No 1 Yes 77 Don’t know 88 Refused 99 No one else in the household
A job in which they or their coworkers use mercury	0 No 1 Yes 77 Don’t know 88 Refused 99 No one else in the household

25. In the past 3 months, have you or your household members used any pesticides, insecticides, or rat poison in or around your home?

₀ No ₁ Yes ₇₇ Don’t know ₈₈ Refused

Now I’ll ask you about medical conditions you might have had.

26. Have you ever had…?

Yellow fever	1 Yes 0 No 77 Don’t know 88 Refused
Dengue	1 Yes 0 No 77 Don’t know 88 Refused
Chikungunya	1 Yes 0 No 77 Don’t know 88 Refused

27. Have you ever been vaccinated for…?

Yellow fever	1 Yes 0 No 77 Don’t know 88 Refused
Dengue	1 Yes 0 No 77 Don’t know 88 Refused

28. In the last 3 months, have you had any of the following genital tract infections or problems…?

Genital herpes	1 Yes 0 No 77 Don’t know 88 Refused
Gonorrhea or chlamydia	1 Yes 0 No 77 Don’t know 88 Refused
Bacterial vaginosis	1 Yes 0 No 77 Don’t know 88 Refused
Trichomonas	1 Yes 0 No 77 Don’t know 88 Refused

The next questions are about smoking, drug use, alcohol, and vitamin use.

29. In the past 3 months, have you …?

Smoked cigarettes	1 Yes 0 No 77 Don’t know 88 Refused
Smoked marijuana	1 Yes 0 No 77 Don’t know 88 Refused
Used drugs such as crack, cocaine, or heroin to get high	1 Yes 0 No 77 Don’t know 88 Refused

30. In the past 3 months, how many alcoholic drinks (such as beer, wine, or spirits) have you had in an average week?

₅ 14 drinks or more a week

₄ 7–13 drinks a week

₃ 4-6 drinks a week

₂ 1–3 drinks a week

₁ Less than 1 drink a week

₀ None

₇₇ Don’t know

₈₈ Refused

31. In the past 3 months, have you regularly taken any vitamin supplements with or without folic acid?

₃ Yes, vitamins with folic acid

₂ Yes, vitamins without folic acid

₁ I took vitamins but I don’t know if there was folic acid in them

₀ No

₇₇ Don’t know

₈₈ Refused

The next questions are about your pregnancies.

32. What was your weight when you got pregnant? ____ kg ₇₇ Don’t know ₈₈ Refused

33. What is your height? _____cm ₇₇ Don’t know ₈₈ Refused

34. How many times were you pregnant before this pregnancy?

_________ times ₇₇ Don’t know ₈₈ Refused

If zero, go to question 38.

35. In how many of your previous pregnancies did you have…

Live birth	__________ pregnancies 77 Don’t know 88 Refused
Miscarriage (loss before 20th week)	__________ pregnancies 77 Don’t know 88 Refused
Stillbirth (loss at or after the 20th week)	__________ pregnancies 77 Don’t know 88 Refused
Abortion	__________ pregnancies 77 Don’t know 88 Refused
Ectopic or molar pregnancy	__________ pregnancies 77 Don’t know 88 Refused

36. During your previous [pregnancy/pregnancies], in how many pregnancies did you …?

Have Pre-eclampsia (high blood pressure in pregnancy)	__________ pregnancies 77 Don’t know 88 Refused
Have Gestational diabetes (diabetes diagnosed in pregnancy)	__________ pregnancies 77 Don’t know 88 Refused
Have A premature birth (delivery before 37 weeks)	__________ pregnancies 77 Don’t know 88 Refused
Have A baby who was born weighing less than 2500g, or 2.5 kg	__________ pregnancies 77 Don’t know 88 Refused
Have a Cesarean section	__________ pregnancies 77 Don’t know 88 Refused
Breastfeed your baby	__________ pregnancies 77 Don’t know 88 Refused

37. When did your last pregnancy end?

__ __/__ __ /__ __ __ __ ₇₇ Don’t know ₈₈ Refused

D D M M Y Y Y Y

38. When was the first day of your last menstrual period?

__ __/__ __ /__ __ __ __ ₇₇ Don’t know ₈₈ Refused

D D M M Y Y Y Y

39. How sure are you about the date of your last menstrual period?

₀ Not sure ₁ Sure ₇₇ Don’t know ₈₈ Refused

40. Did you use any fertility treatments to help you get pregnant? Choose all that apply.

₀ No, I did not use any fertility treatments

₄ Yes, medicine for ovarian stimulation, such as clomiphene citrate or Femara

₃ Yes, intrauterine insemination

₂ Yes, in vitro fertilization (IVF)

₁ Yes, intracytoplastmic sperm injection

₇₇ Don’t know

₈₈ Refused

41. Thinking back to right before you became pregnant, which of these statements best describes how you felt about being pregnant?

₄ I wanted to be pregnant sooner

₃ I wanted to be pregnant later

₂ I wanted to be pregnant then

₁ I didn’t want to be pregnant then or at any time in the future

₇₇ I don’t know

₈₈ Refused

These next few questions are about your recent sexual experiences.

42. In the past 3 months, how many different men have you had sex with?

₀ None ₁ 1 ₂ 2 ₃ 3 or more ₇₇ Don’t know ₈₈ Refused

If None: go to question 52.

43. In the past 3 months, how often have you had vaginal sex with a man? Choose the best answer.

₁ Once a day or more

₂ Two or more times a week

₃ Once a week

₄ A few times a month

₅ Once a month

₆ Less than once a month

₇₇ Don’t know

₈₈ Refused

44. When you had sex in the past 3 months, how often has your male partner used a condom?

₂ Always ₁ Sometimes ₀ Never ₇₇ Don’t know ₈₈ Refused

45. Since you found out that you were pregnant, have you and your male partner changed how often you use condoms during sex?

₁ Yes, we use them more often

₂ Yes, we use them less often

₃ No, we haven’t changed how often we use condoms

₀ I haven’t had regular sex with a male partner

₇₇ Don’t know

₈₈ Refused

46. In the past 3 months, have you…?

Received oral sex from someone	1 Yes 0 No 77 Don’t know 88 Refused
Performed oral sex on someone	1 Yes 0 No 77 Don’t know 88 Refused
Had anal sex	1 Yes 0 No 77 Don’t know 88 Refused

47. What is your marital status?

₁ Married

₂ Union libre

₃ Single, divorced, or widowed

₃ Other

₇₇ Don’t know

₈₈ Refused

48. Do you live in the same household as a husband or male partner?

₀ No ₁ Yes ₇₇ Don’t know ₈₈ Refused

If yes: Is your husband or male partner circumcised?

₀ No ₁ Yes ₇₇ Don’t know ₈₈ Refused

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