2 2018 MCH Survey Juris Module_AS_English_Formatted

American Samoa

I will start by asking a few questions about your health.

1. [ONLY ASK THIS QUESTION IF CHILD IS 0-1 YEAR OLD AND IF BIOLOGICAL MOTHER]

Did you have any prenatal care during this most recent (or current) pregnancy? Prenatal care is given by a healthcare provider and includes a physical exam, weight checks, and providing a urine sample. Depending on the stage of the pregnancy, healthcare providers may also do blood tests and imaging tests, such as ultrasound exams. These visits also include discussions about the mother’s health, the infant’s health, and any questions about the pregnancy.

1. ☐ Yes

2. ☐ No [Go to AS3]

77. ☐ Don’t know [Go to AS3]

99. ☐ Prefer not to answer [Go to AS3]

2. [ONLY ASK THIS QUESTION IF CHILD IS 0-1 YEAR OLD AND IF BIOLOGICAL MOTHER]

How many weeks or months pregnant were you when you had your first visit for prenatal care?

Weeks OR Months

77. ☐ Don’t Know

99. ☐ Prefer not to answer

3. In the past 12 months, have you had any trouble getting health care for yourself? By health care, we mean medical care as well as other kinds of care like dental care, vision care, and mental health services.

   1. ☐ Yes

   2. ☐ No [GO TO AS4]

77. ☐ Don’t Know [GO TO AS4]

99. ☐ Prefer not to answer [GO TO AS4]

[If yes] Why did you have trouble getting health care for yourself?
Check all that apply.

	YES	NO	Don’t Know	Prefer Not to Answer
AS3a. I couldn’t afford it.	1 ☐	2 ☐	3 ☐	4 ☐
AS3b. I did not know where to go.	1 ☐	2 ☐	3 ☐	4 ☐
AS3c. It was too far away.	1 ☐	2 ☐	3 ☐	4 ☐
AS3d. I could not get there when it was open.	1 ☐	2 ☐	3 ☐	4 ☐
AS3e. I could not get an appointment soon enough.	1 ☐	2 ☐	3 ☐	4 ☐
AS3f. I did not have transportation.	1 ☐	2 ☐	3 ☐	4 ☐
AS3g. I didn’t have time to go.	1 ☐	2 ☐	3 ☐	4 ☐
AS3h. I was worried that it wasn’t covered under my insurance.	1 ☐	2 ☐	3 ☐	4 ☐
AS3i. Some other reason, please specify	1 ☐	2 ☐	3 ☐	4 ☐

Now I will ask a few questions about your child’s diagnosis and health care.

4. [ONLY ASK THIS QUESTION IF CHILD IS CSHCN]

Was it difficult to have your child diagnosed?

1. ☐ Yes

2. ☐ No

77. ☐ Don’t Know

99. ☐ Prefer not to answer

[If yes] please specify:

5. [ONLY ASK THIS QUESTION IF CHILD IS 12-17 YEARS OLD]

The next 2 questions ask about bullying. Bullying is when 1 or more students tease, threaten, spread rumors about, hit, shove, or hurt another student over and over again. It is not bullying when 2 students of about the same strength or power argue or fight or tease each other in a friendly way.

Has your child ever been bullied on school property?

1. ☐ Yes

2. ☐ No

77. ☐ Don’t Know

99. ☐ Prefer not to answer

6. [ONLY ASK THIS QUESTION IF CHILD IS 12-17 YEARS OLD]

Has your child ever been electronically bullied? (Count being bullied through texting, Instagram, Facebook, or other social media.)

1. ☐ Yes

2. ☐ No

77. ☐ Don’t Know

99. ☐ Prefer not to answer

If child had ear infection in past 12 months:

7. Was your child recommended to have drainage tubes inserted in his or her ears?

   1. ☐ Yes

77. ☐ No

78. ☐ Don’t Know

99. ☐ Prefer not to answer

[If yes] Were the tubes inserted?

1. ☐ Yes

2. ☐ No

77. ☐ Don’t Know

99. ☐ Prefer not to answer

[If no] why were the tubes not inserted? Check all that apply.

	YES	NO	Don’t Know	Refused to Answer
AS7a. I was scared something might go wrong	1 ☐	2 ☐	77 ☐	99 ☐
AS7b. I didn’t have enough money	1 ☐	2 ☐	77 ☐	99 ☐
AS7c. I didn’t have any transportation to get to the clinic or doctor’s office	1 ☐	2 ☐	77 ☐	99 ☐
AS7d. I had too many other things going on	1 ☐	2 ☐	77 ☐	99 ☐
AS7e. I couldn’t take time off from work or school	1 ☐	2 ☐	77 ☐	99 ☐
AS7f. I didn’t have anyone to take care of my children	1 ☐	2 ☐	77 ☐	99 ☐
AS7g. Other reason, please specify	1 ☐	2 ☐	77 ☐	99 ☐