Hospital-based Survey for Fathers - English

Attachment 8a

Hospital-based Survey for Fathers (English)

The first questions are about you.

1. (ZPER 1) What is your date of birth?

_____ /_____ /_____

Month/ Day / Year

2. (ZPER 4) What municipality do you live in now? If you live in multiple locations, please write the name of the municipality where you live most of the time.

_____________________________

_____ I am currently not living in Puerto Rico

3. (ZPER 2) What is the highest grade or year of school you completed?

Less than high school Diploma

High school diploma or GED

Some college

Complete college

Competed graduate school

4. (ZPER 5) Are you currently married?

Yes

No

The next questions are about Zika virus. Zika virus infection is an illness that is most often spread by the bite of a mosquito but may also be spread by having sex with a man who has the Zika virus.

5. (ZPER 7- modified) During your wife or partners pregnancy with your new baby, how worried were you about getting infected with Zika virus? Check ONE answer

Very worried

Somewhat worried

Not at all worried

I had never heard of Zika virus  Go to Question 14

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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74,  Atlanta, Georgia 30333; ATTN:  PRA (xxx-xxxx).

6. (ZPER 7- modified) During your wife or partners pregnancy with your new baby, how worried were you about the mother of your child getting infected with Zika virus? Check ONE answer

Very worried

Somewhat worried

Not at all worried

7. (ZPER 8 – modified) During your wife or partners pregnancy with your new baby, how worried were you about having a child with microcephaly or another birth defect linked to Zika virus? Microcephaly is a birth defect where a baby’s head is smaller than expected when compared to babies of the same sex and age.

Very worried

Somewhat worried

Not at all worried

8. (CAPRZ 7) Have you made any changes to your daily routine since learning more about Zika virus and the risk to infect your female partner?

No

Yes

9. (New) Throughout the last 9 months, how often have you spoken to the mother of your child about Zika? Check ONE answer

Every day

2 -6 days a week

Once a week

A few times a month

Less than once a month

Never  Go to Question 10

10. (New) When you spoke to the mother of your child about Zika, what topics did you discuss? Mark Yes for topics you discussed and No for topics you didn’t discuss.

Yes No

1. Risks associated to Zika virus  

2. Transmission of Zika virus through sexual intercourse  

3. Use of condoms during sexual intercourse  

4. Possibility of postponing having a child  

5. Worries about the possibility of having a baby with birth defects  

11. (ZPER 10 – modified) At any time during the pregnancy of your wife or partner, did a doctor, nurse, or other healthcare worker talk to you about Zika virus?

Yes, a healthcare worker talked with me without my asking about it

Yes, a healthcare worker talked with me, but only after I asked about it

No, they didn’t talk to me about it

No, I didn’t see a healthcare worker for myself during the pregnancy of my wife or partner

12. (ZPER 12 – modified) Have you been tested for Zika virus? Check ALL that apply

Yes, before we found out we were pregnant

Yes, during the pregnancy

No

13. (ZPER 13 –modified) Has a doctor, nurse or other healthcare worker told you that you had Zika virus infection?

Yes, after I got tested

Yes, but I was never tested

No

I don’t remember

The next questions are about avoiding mosquito bites.

14. (ZPER 14) During your wife or partner’s pregnancy with your new baby, did you do any of the following things to avoid mosquito bites in your home?

Yes No

1. Always used screens on open doors  

2. Always used screens on open windows  

3. Kept unscreened doors and windows closed  

4. Always used fans or air conditioning  

5. Eliminated accumulated water from my house and yard on a weekly basis  

6. Slept under a mosquito bed net  

7. Sprayed the inside of my house for mosquitoes  

8. Sprayed the outside of my home and in my yard for mosquitoes  

9. Applied larvacides around the outside of my home  

15. ( ZPER 15 – modified) During your wife or partner’s pregnancy with your new baby, how often did you use a mosquito repellent on your skin when you went outside, even if you were only outside for a short time?

Every day

Most days

Some days

Only when I saw mosquitoes

Never  Pase a la Pregunta 17

16. (ZPER 16) When you used mosquito repellent on your exposed skin, how many times a day did you apply it?

More than once a day
Once a day

17. (ZPER 17 – modified) When you did not wear mosquito repellent during the pregnancy of your most recent child, what were your reasons for not wearing it? Check ALL that apply

I did not like the way it smelled

I did not like the way it made my skin feel

I worried about the chemicals in the repellent harming me

Mosquito repellent was too expensive

I forgot to apply it

I didn’t think I needed it

Other reason  Please tell us: ______________________________________________

The next questions are about contraception use.

18. (New) In your opinion, who should be responsible for the use of contraception?

Myself

My female partner

Both

I don’t use contraception for personal reasons

19. (ZCAN 16 - modified) Which of the following is most important to you when choosing the method of contraception? Check ONE answer.

Easy to use

Easy to get

How well it works

My female partner recommended it

My physician recommended it

My friends recommended it

It is affordable

20. (ZPER 26) Did you have sex at any time with your wife or female partner during her pregnancy?

Yes No, to avoid Zika No, for another reason

a. First 3 months   

b. Second 3 months   

c. Last 3 months   

21. (ZPER 27)How often did you use a condom when you had sex during the pregnancy:

Every time Sometimes Never

a. First 3 months   

b. Second 3 months   

c. Last 3 months   

If you used a condom every time you had sex with your wife or partner during her pregnancy, go to Question 23. If not, go to Question 22.

22. (ZPER 28 – modified) What were your reasons for not using condoms every time when having sex with your wife or partner during her pregnancy? Check ALL that apply

I didn’t know she was pregnant

I didn’t think I needed to use condoms during pregnancy

I didn’t think a condom would prevent Zika infection

I didn’t think I had Zika virus

I didn’t want to use condoms

My partner didn’t want to use condoms

I could not get condoms when I needed them

I could not afford condoms

I forgot to use condoms

Other  Please tell us: ______________________________

23. (ZPER 31 – modified) Thinking back to just before your wife or partner got pregnant with your new baby, how did you feel about having a baby? Check ONE answer

I wanted to have a child later, because of the risks associated with Zika virus

I wanted to have a child later, because of other reasons

I wanted to have a child sooner

I wanted to have a child at that moment

I never wanted to have a child

I wasn’t sure what I wanted

24. (ZPER 34 – modified) What is the MAIN method of birth control are you planning to use now? Check ONE answer

Condoms

Vasectomy

Withdrawal (Pull-out method)

Natural Family Planning (including rhythm method)

My wife or female partner will adopt a birth control method

I don’t know

The next questions are about your involvement in the pregnancy of your wife or partner.

25. (New) Did you go with your wife or female partner to the prenatal care visits?

Yes, I went to all of the prenatal care visits

Yes, I went to some of the prenatal care visits

No

26. (ZPER 36 – modified) During any of the prenatal care visits, did a doctor, nurse, or other healthcare worker talk to you about any of the things listed below? For each item, check No if they did not or Yes if they did.

Yes No

1. How to prevent mosquito bites during the pregnancy  

2. Using condoms during sex to prevent Zika infection  

3. Types of clothes to wear to prevent mosquito bites  

4. Using mosquito repellent on my skin  

5. Ways I could provide support to my partner during pregnancy  

27. (PRAMS – standard question C12) Please tell us about your MAIN job during your most recent pregnancy.  What was your job title and what were your usual activities or duties?

Job title:

Job duties:

C28. (PRAMS standard question C13) Thinking about your MAIN job during your most recent pregnancy, what type of company did you work for (what did the company do or make)?

Type of company:

I don’t know

PRAMS-ZPER 2.0 Paternal Survey – Page 11 of 11