Online Survey - Staff English

Attachment N-3. Online survey for Z-CAN clinic staff

No.	Question	Coding	Skip
1	What is your role in the clinic?	Nurse 1 Medical assistant or nurse’s aide 2 Health educator 3 Other staff___________ 4
2	How many years has it been since you completed your most recent clinical training (e.g., nursing school, other schooling)?	Less than 5 years 1 5-14 years 2 15-24 years 3 25 years of more 4 I have not completed any clinical training 5
3	On average, about how many female patients of reproductive age are seen at your clinic per week?	___ female patients of reproductive age
4	To approximately what percent of all of your female patients of reproductive age do you provide family planning services?	1-24% 1 25-49% 2 50-74% 3 75% or more 4
The following questions focus on the implementation of the Z-CAN program in your clinic.
5	Currently, through the Z-CAN program, which contraceptive methods are provided at your clinic on-site? Hormonal IUD (Mirena, Skyla, Liletta) Copper IUD (ParaGard) Implant (Nexplanon) Contraceptive shot/injection (DepoProvera) Birth control pills Contraceptive ring (Nuvaring) Contraceptive patch (Xulane) Condoms Other____________	No 1 Yes 2 Note- in the online survey, these questions will be formatted as a table
6	Since your clinic started to provide Z-CAN services, how often are patients able to receive these contraceptive methods on the same day that they request it? Hormonal IUD Copper IUD Implant Contraceptive injection Birth control pills Contraceptive ring Contraceptive patch Condoms	Never 1 Rarely 2 Sometimes 3 Very often 4 Always 5
7	How long do you typically spend with a patient conducting patient-centered contraceptive counseling as part of the Z-CAN program?	Less than 5 minutes 1 5-10 minutes 2 11-20 minutes 3 More than 20 minutes 4 I don’t provide patient-centered contraceptive counseling 5
8	Have any of your Z-CAN patients had to provide out-of-pocket payment for the contraceptive method they received?	No 1 Yes 2
9	Have any of your Z-CAN patients had to provide out-of-pocket payment for a Z-CAN service (contraceptive counseling, IUD or implant insertion or removal)?	No 1 Yes 2
10	In the past 60 days, has your clinic been able to consistently maintain a supply of all reversible contraceptive methods on-site (e.g. IUD, implant, injectables, pills, patch, ring, condoms)?	No 1 Yes 2 Not sure 3	212 312
11	For which method(s) has your clinic NOT been able to consistently maintain an on-site supply? (check all that apply)	Hormonal IUD 1 Copper IUD 2 Implant 3 Contraceptive injection 4 Birth control pills 5 Contraceptive ring 6 Contraceptive patch 7 Condoms 8
12	How satisfied are you with the following components of the Z-CAN program? a. Training b. Z-CAN toolkit c. Z-CAN promotion/community outreach d. On-going support e. Product re-ordering f. Overall program	Very dissatisfied 1 Dissatisfied 2 Neutral 3 Satisfied 4 Very Satisfied 5
13	If you have had questions about an aspect of the Z-CAN program, were you able to have your questions answered by Z-CAN program staff in a timely manner?	No 1 Yes 2 Not applicable 3
The following questions ask about your practices and opinions related to providing contraception.
14	How safe do you consider the hormonal IUD to be for these groups of female patients: Adolescents? Postpartum women? Women with a history of a sexually transmitted disease? Nulliparous women?	Safe 1 Unsafe 2 Don’t know 3 Note- in the online survey, these questions will be formatted as a table
15	How safe do you consider the copper IUD to be for these groups of female patients: Adolescents? Postpartum women? Women with a history of a sexually transmitted disease? Nulliparous women?	Safe 1 Unsafe 2 Don’t know 3
16	How safe do you consider the implant to be for these groups of female patients: Adolescents? Women < 30 days postpartum (breastfeeding or non-breastfeeding)? Women with hypertension? Women with a history of deep venous thrombosis or pulmonary embolism?	Safe 1 Unsafe 2 Don’t know 3
17	How safe do you consider combined hormonal contraceptives (pills, patch, ring) to be for the following groups of female patients: Adolescents? Women < 30 days postpartum (breastfeeding or non-breastfeeding)? Women with hypertension? Women with a history of deep venous thrombosis or pulmonary embolism?	Safe 1 Unsafe 2 Don’t know 3
18	For each of the following contraceptive methods, how safe do you think it is to start a woman on the day of her visit regardless of the timing of her menses if you are reasonably certain she is not pregnant? a. Intrauterine devices (hormonal IUD or copper IUD) b. Implant c. Contraceptive injection d. Combined hormonal contraceptives (pills, patch, ring)	Safe 1 Unsafe 2 Don’t know 3
19	State whether you think the following statements are true or false. a. The IUD and implant are the most effective forms of reversible contraception. b. IUDs can be inserted immediately after a woman gives birth. c. Patients must have a chlamydia test within the past three months for an IUD insertion. d. Patients must have a Pap smear within the past year for an IUD insertion. e. In an IUD user with pelvic inflammatory disease who is clinically well, the IUD should be removed	True 1 False 2
20	When discussing family planning with your Z-CAN patients, how often do you do the following? a. Assess the patient’s reproductive life plan (i.e., asked about her intentions regarding the number and timing of pregnancies in the context of her personal values and life goals) b. Discuss all contraceptive methods c. Use an informed consent for insertion of IUD or implants d. Inform women who choose an IUD or implant how they can have their device removed e. Discuss condom use to prevent sexually transmitted diseases f. Discuss the risks associated with Zika virus infection during pregnancy	Never 1 Not often 2 Often 3 Very often 4
21	When initiating the following contraceptive methods, please indicate if you or your clinic require these exams and tests for a healthy patient Hormonal IUD Copper IUD Implant Contraceptive injection Progestin-only birth control pills Combined hormonal birth control pills, contraceptive ring or contraceptive patch	Pregnancy test No 1 Yes 2 Blood pressure No 1 Yes 2 Clinical breast exam No 1 Yes 2 Bimanual exam and cervical inspection No 1 Yes 2 Cervical cytology (Pap smear) No 1 Yes 2 Chlamydia/ gonorrhea screening No 1 Yes 2
22	How confident are you in the following skills: Giving injections Patient-centered contraceptive counseling	No confidence 1 Slight confidence 2 Moderate confidence 3 High confidence 4
23	Do you agree or disagree with this statement: Contraception is a key strategy to prevent Zika-related pregnancy complications among women who want to delay or avoid pregnancy.	Strongly disagree 1 Disagree 2 Neutral 3 Agree 4 Strongly agree 5
24	When you see a woman of reproductive age who wishes to delay or avoid pregnancy, how often do you discuss the following Zika prevention methods with her? Avoiding mosquitoes bites Contraception Condom use	Never 1 Rarely 2 Sometimes 3 Very often 4 Always 5
25	Do you have any other comments or suggestions to improve the Z-CAN program?
Thank you so much for participating in this survey and in the Z-CAN program. The Z-CAN program will use data from these surveys to improve the Z-CAN program experience in Puerto Rico. If you have any follow-up questions or ideas about the implementation of the Z-CAN program, please contact the Z-CAN program staff at [email protected].