6 2018 MCH Survey Juris Module_MarshallIslands_English_For

Questionnaire and Data Collection Testing, Evaluation, and Research for the Health Resources and Services Administration (HRSA)

2018 MCH Survey Juris Module_MarshallIslands_English_Formatted

Title V Maternal and Child Health (MCH) Block Grant Jurisdictional MCH Survey Instrument

OMB: 0915-0379

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Marshall Islands

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

I am going to ask a few questions about your health.

  1. During your most recent pregnancy, how many times did you visit a doctor, nurse, or other health care professional to receive a PRENATAL check-up?

    1. ☐ 0 visits

    2. ☐ 1 visit [Go to MI2]

    3. ☐ 2 visits [Go to MI2]

    4. ☐ 3 visits [Go to MI2]

    5. ☐ 4 or more visits [Go to MI2]

    1. ☐ Don’t Know [Go to MI2]

    1. ☐ Prefer not to answer [Go to MI2]

[If 0 visits] Did any of these things keep you from having a prenatal checkup?


YES

NO

Don’t Know

Prefer Not to Answer

MI1a. I couldn’t get an appointment when I wanted one

1 ☐

2 ☐

77 ☐

99 ☐

MI1b. I didn’t have any transportation to get to the clinic or doctor’s office

1 ☐

2 ☐

77 ☐

99 ☐

MI1c. The doctor or my health plan would not start as early as I wanted

1 ☐

2 ☐

77 ☐

99 ☐

MI1d. I had too many things going on

1 ☐

2 ☐

77 ☐

99 ☐

MI1e. I couldn’t take time off from work or school

1 ☐

2 ☐

77 ☐

99 ☐

MI1f. I didn’t have anyone to take care of my children

1 ☐

2 ☐

77 ☐

99 ☐

MI1g. I didn’t know that I was pregnant

1 ☐

2 ☐

77 ☐

99 ☐

MI1h. I didn’t have health insurance to cover the cost of the visit

1 ☐

2 ☐

77 ☐

99 ☐

MI1i. I felt fine and did not think I needed to have a visit

1 ☐

2 ☐

77 ☐

99 ☐

MI1j. I didn’t want prenatal care

1 ☐

2 ☐

77 ☐

99 ☐

MI1k. I didn’t want anyone else to know I was pregnant

1 ☐

2 ☐

77 ☐

99 ☐

MI1l. Other, please specify

1 ☐

2 ☐

77 ☐

99 ☐

We would like to ask you some specific questions about your experiences with breast and cervical cancer screening.

  1. [ONLY ASK THIS QUESTION OF WOMEN 25-49 AND BIOLOGICAL MOTHER]

Have you ever had a pap smear done by a doctor or other health professional?

    1. ☐ Yes

    2. ☐ No

    1. ☐ Don’t Know [Go to MI3]

    1. ☐ Prefer not to answer [Go to MI3]

[If no] Why did you not receive a pap smear?

[Go toMI3]

[If yes] When did you have your MOST RECENT pap smear?

    1. ☐ A year ago or less

    2. ☐ More than 1 year, but not more than 2 years

    3. ☐ More than 2 years, but not more than 3 years

    4. ☐ More than 3 years, but not more than 5 years

    5. ☐ Over 5 years ago

    1. ☐ Don’t Know

    1. ☐ Prefer not to answer

What was the MAIN reason you had this test?

    1. ☐ Part of a routine exam

    2. ☐ Because of a problem

    3. ☐ Other reason

    1. ☐ Don’t Know

    1. ☐ Prefer not to answer

Did you receive the result?

    1. ☐ Yes

    2. ☐ No

    1. ☐ Don’t Know

    1. ☐ Prefer not to answer

  1. [ONLY ASK THIS QUESTION OF WOMEN 25-49 AND IF BIOLOGICAL MOTHER]

Have you ever had a mammogram? A mammogram is an x-ray taken only of the breast by a machine that presses against the breast.

    1. ☐ Yes

    2. ☐ No

    1. ☐ Don’t know [Go to MI4]

    1. ☐ Prefer not to answer [Go to MI4]

[If no] Why did you not have a mammogram?

[If yes] When did you have your MOST RECENT mammogram?

    1. ☐ A year ago or less

    2. ☐ More than 1 year, but not more than 2 years

    3. ☐ More than 2 years, but not more than 3 years

    4. ☐ More than 3 years, but not more than 5 years

    5. ☐ Over 5 years ago

    1. ☐ Don’t Know

    1. ☐ Prefer not to answer

  1. [ONLY ASK THIS QUESTION IF BIOLOGICAL MOTHER]

Have you ever had a breast exam done by a doctor or other health professional to check for lumps or other signs of breast cancer? A breast exam is when the breasts are felt by a doctor or other health professional to check for lumps or other signs of breast cancer.

    1. ☐ Yes

    2. ☐ No [Go to M15]

    1. ☐ Don’t Know [Go to M15]

    1. ☐ Prefer not to answer [Go to M15]

[If yes] When did you have your MOST RECENT breast exam?

    1. ☐ A year ago or less

    2. ☐ More than 1 year, but not more than 2 years

    3. ☐ More than 2 years, but not more than 3 years

    4. ☐ More than 3 years, but not more than 5 years

    5. ☐ Over 5 years ago

    1. ☐ Don’t Know

    1. ☐ Prefer not to answer

  1. Do you know where to find good information and help with the following issues if needed about the following issues?

    YES

    NO

    Don’t Know

    Prefer Not to Answer

    MI5a. Awareness of and access to resources for women experiencing gender violence.

    1 ☐

    2 ☐

    77 ☐

    99 ☐

    MI5b. Awareness of and access to resources on diabetes, smoking, and drinking.

    1 ☐

    2 ☐

    77 ☐

    99 ☐

    MI5c. Awareness of nutrition, access to resources to obtain food.

    1 ☐

    2 ☐

    77 ☐

    99 ☐

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

Are you aware of the following mosquito borne illnesses?


YES

NO

Don’t Know

Prefer Not to Answer

MI6a. Zika Virus

1 ☐

2 ☐

77 ☐

99 ☐

MI6b. Dengue Fever

1 ☐

2 ☐

77 ☐

99 ☐

MI6c. Chickingunya

1 ☐

2 ☐

77 ☐

99 ☐

Now we have a few questions about car safety.

  1. [ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD]

When your child rides in a car, truck, or van, how often does he or she ride in an infant car seat?

    1. ☐ Always

    2. ☐ Often

    3. ☐ Sometimes

    4. ☐ Rarely

    5. ☐ Never

    1. ☐ Don’t Know

    1. ☐ Prefer not to answer

  1. [ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD]

When your child rides in an infant car seat, is he or she usually in the front or back seat of the car, truck, or van?

    1. ☐ Front seat

    2. ☐ Back seat

    1. ☐ Don’t Know

    1. ☐ Prefer not to answer

  1. [ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD]

When your child rides in an infant car seat, is he or she usually facing forward or facing the rear of the car, truck, or van?

    1. ☐ Facing forward

    2. ☐ Facing the rear

    1. ☐ Don’t Know

    1. ☐ Prefer not to answer

  1. [ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD]

Does the car, truck, or van that your child usually rides in have an airbag on the passenger side?

    1. ☐ Yes

    2. ☐ No

    1. ☐ Don’t Know

    1. ☐ Prefer not to answer

  1. How often do you use seat belts when you drive or ride in a car? Would you say:

    1. ☐ Always

    2. ☐ Nearly always

    3. ☐ Sometimes

    4. ☐ Rarely

    5. ☐ Never

    6. ☐ Never drive or ride in a car

    1. ☐ Don’t Know

    1. ☐ Prefer not to answer

[ONLY ASK THIS QUESTION IF BIOLOGICAL MOTHER]

Now I would like to ask you some questions about family planning and prenatal care.

  1. Are you aware of family planning methods? Family planning methods include things that women or their partners may use to prevent pregnancy such as birth control, condoms, implants, or withdrawal.

    1. ☐ Yes

    2. ☐ No

    1. ☐ Don’t Know [GO TO MI13 (15-43); MI14 (>15, 43<)]

    1. ☐ Prefer not to answer [GO TO MI13 (15-43); MI14 (>15, 43<)]

[If yes] Have you used any family planning methods?

    1. ☐ Yes

    2. ☐ No

    1. ☐ Don’t Know

    1. ☐ Prefer not to answer

[If no] Have you tried to find resources on family planning methods?

    1. ☐ Yes

    2. ☐ No

    1. ☐ Don’t Know

    1. ☐ Prefer not to answer

  1. [ONLY ASK THIS QUESTION OF WOMEN AGE 15-44 AND IF BIOLOGICAL MOTHER]

Do you currently use any family planning services, such as birth control, from the Ministry of Health and Human Services clinic?

    1. ☐ Yes

    2. ☐ No

    1. ☐ Don’t Know

    1. ☐ Prefer not to answer

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

Have you ever been counseled on breastfeeding during prenatal care?

    1. ☐ Yes

    2. ☐ No

    1. ☐ Don’t Know

    1. ☐ Prefer not to answer

  1. Are you aware of the immunization services available and the importance of immunizing your child?

    1. ☐ Yes

    2. ☐ No

    1. ☐ Don’t Know

    1. ☐ Prefer not to answer

  1. Are you aware that there are agencies who can provide assistance to women experiencing gender violence?

    1. ☐ Yes

    2. ☐ No

    1. ☐ Don’t Know

    1. ☐ Prefer not to answer

  1. Have you been screened for diabetes?

    1. ☐ Yes

    2. ☐ No

    1. ☐ Don’t know [Go to MI18 (CSHCN); MI20 (not CSHCN, 0-5); end(not CSHCN, 6-11)]

    1. ☐ Prefer not to answer [Go to MI18 (CSHCN); MI20 (not CSHCN, 0-5); end (not CSHCN, 6-11)]

[If yes] What was the result?

    1. ☐ Negative/Do not have diabetes

    2. ☐ Positive/Have diabetes

    1. ☐ Don’t Know

    1. ☐ Prefer not to answer

[If no] Why have you not been screened for diabetes?

    1. ☐ Don’t Know

    1. ☐ Prefer not to answer

The next few questions are about health care services for your child.

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

Are you aware that there are agencies that can provide assistance to disabled children?

    1. ☐ Yes

    2. ☐ No

    1. ☐ Don’t Know

    1. ☐ Prefer not to answer

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

Are you aware that screening of children with disabilities can be done at the hospital?

    1. ☐ Yes

    2. ☐ No

    1. ☐ Don’t Know

    1. ☐ Prefer not to answer

  1. [ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD]

Has your child ever been given a developmental milestone assessment before he or she was 6 months old?

    1. ☐ Yes

    2. ☐ No

    1. ☐ Don’t Know

    1. ☐ Prefer not to answer

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