ZPER Telephone Follow-Up Survey - English

Attachment 9a

Telephone Follow-up Survey (English)

We would like to ask you some questions about your health and experiences since the birth of your recent baby.

1. (Core 46) Since your new baby was born, have you had a postpartum checkup for yourself? A postpartum checkup is the regular checkup a woman has about 4-6 weeks after she gives birth.

No

Yes  Go to Question 3

2. (J3) Did any of these things keep you from having a postpartum checkup? Check ALL that apply

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

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

I couldn’t get an appointment when I wanted one

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

I had too many things going on

I couldn’t take time off from work

Other  Please tell us: ____________________________

If you did not have a postpartum checkup, go to Question 5.

3. (Core 47 + ZPER 36) During your postpartum checkup, did a doctor, nurse, or other health care worker do any of the following things? For each item, check No if they did not do it or Yes if they did.

No Yes

1. Talk to me about clothes to wear to prevent mosquito bites  

2. Talk to me about using mosquito repellent on my skin  

3. Talk to me about using condoms during sex to prevent Zika infection  

4. Talk to me about birth control methods I can use after giving birth  

5. Give or prescribe me a contraceptive method such as the pill, patch,

shot (Depo-Provera^®), NuvaRing^®, or condoms  

6. Insert an IUD (Mirena^®, ParaGard^®, Liletta^®, or Skyla^®) or a contraceptive

implant (Nexplanon^® or Implanon^®)  

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).

4. (NEW) Since your new baby was born, has a doctor, nurse, or other health care worker told you that you have any of the following health conditions? For each one, check No if you were not told that you have the condition, or Yes if you were.

No Yes

1. Diabetes

2. High blood pressure

3. Depression

4. Anxiety

5. Zika virus infection

5. (V2) Since your new baby was born, have you used any of these services? For each one, check No if you did not use the service or Yes if you did.

No Yes

a. Counseling for depression or anxiety  

b. WIC or the Special Supplemental Nutrition Program for Women, Infants, and Children

c. Home Visiting Program or Programa de Visitas al Hogar

d. Healthy Families Puerto Rico or Familias Saludables Puerto Rico

e. United for Early Childhood or Unidos por la Niñez Temprana

f. Early intervention services or Avanzando Juntos

g. The program for integrated adolscent health services or Programa SISA

h. The Adolescent Education Program for Personal Responsibility in Puerto Rico or PR-PREP

The next questions are about your new baby.

6. (Core 32) Is your baby alive now?

No  We are very sorry for your loss. Go to Question 24

Yes

7. (Core 33) Is your baby living with you now?

No  Go to Question 24

Yes

8. (Core 35) Did you ever breastfeed or pump breast milk to feed your new baby, even for a short period of time?

No  Go to Question 11

Yes

9. (Core 36) Are you currently breastfeeding or feeding pumped milk to your new baby?

No

Yes  Go to Question 11

10. (Core 37) How many weeks or months did you breastfeed or feed pumped milk to your baby?

Less than 1 week

______Weeks OR _____ Months

11. (X9 - modified) Has your new baby had a health care visit with a doctor, nurse, or other health care worker since you left the hospital where your baby was born?

No

Yes Go to Question 13

12. (X2-modified) Did any of these things keep your baby from having a health care visit? Check ALL that apply

I don’t have health insurance for my baby

I don’t have enough money to pay for the visit

I have no way to get my baby to the clinic or doctor’s office

I don’t have anyone to take care of my other children

I can’t get an appointment

I don’t think my new baby needs a health care visit

Other  Please tell us: ___________________________

If your new baby has never had a health care visit with a doctor, nurse, or other health care worker after you left the hospital, got to Question 15.

13. (X7-modified) How many times has your new baby been to a doctor, nurse, or other health care worker for a health care visit? (It may help to use the calendar.)

______  Times

I don’t remember

14. (X8-modified) Where do you usually take your new baby for health care visits? Check ONE answer

Private doctor’s office

Health Department Clinic (IPA Clinics)

Community Health Center (330 Clinics)

Regional Pediatric Center

Hospital Emergency Room

Hospital Outpatient Clinic

Other  Please tell us: _________________________

15. (OK74 P7) Do you have someone you think of as your baby’s personal doctor or nurse? A personal doctor or nurse is a health professional who knows your baby well and is familiar with your baby’s health history. (This can be a family doctor, a pediatrician, a specialist doctor, a nurse practitioner, or a physician assistant.)

No

Yes, one person

Yes, more than one person

16. (NEW) Since your new baby was born, has a doctor, nurse, or other health care worker talked with you about any of the following things? For each thing, check No if they did not tell you or Yes if they did.

No Yes

1. Dressing my baby in long sleeves and long pants to avoid mosquito bites

2. Using mosquito repellent on my baby’s exposed skin or clothing

3. Putting a mosquito net over my baby’s crib or bed

4. What the signs and symptoms of Zika virus infection are in a baby

17. (NEW) Has a doctor, nurse, or other health care worker told you that your new baby was infected with Zika virus during your pregnancy?

No

Yes  Go to Question 19

18. (New) How worried are you about your new baby getting infected with Zika virus now? Check ONE answer

Very worried

Somewhat worried

Not at all worried

19. (NEW) Does your new baby have any of the following health conditions? For each one, check No if your baby does not have the condition, or Yes if you they do.

No Yes

1. Hearing problems

2. Vision problems

3. Poor weight gain

4. Difficulties feeding

5. Smaller than normal head size

6. Muscle weakness

7. Deformity of the feet

8. Convulsions

If your baby does not have any of the health conditions listed above, go to Question 22.

20. (NEW) Has your new baby’s regular doctor suggested that you take your baby to see a specialist doctor for help with his or her health conditions?

No

Yes

21. (NEW) Have you been asked if you would like to talk to other families who have had babies with health conditions similar to those of your new baby?

No

Yes

22. (NEW) Have you received any of the following services for your new baby? For each one, check No if you did not receive the service for you baby or Yes if you did.

No Yes

a. A scan of my baby’s head, for example a CT scan or MRI  

b. A hearing test  

c. An eye exam

d. An assessment of how your baby is developing

e. An evaluation by a specialists for physical therapy

f. Assistance from a nutritionist

23. (HRSA) Would you say that you have someone that you can turn to for day-to-day emotional support with taking care of your new baby?

No

Yes

The next questions are about the use of contraception.

24. (Core 43) Are you or your husband or partner doing anything now to keep from getting pregnant? Some things people do to keep from getting pregnant include having their tubes tied, using birth control pills, condoms, withdrawal, or natural family planning.

No

Yes  Go to Question 26

25. (Core 44) What are your reasons or your husband’s or partner’s reasons for not doing anything to keep from getting pregnant now? Check ALL that apply

I want to get pregnant

I am pregnant now

I had my tubes tied or blocked

I don’t want to use birth control

I am worried about side effects from birth control

I am not having sex

My husband or partner doesn’t want to use anything

I have problems paying for birth control

Other  Please tell us: ________________________

If you or your husband or partner is not doing anything to keep from getting pregnant now, go to Question 27.

26. (Core 45) What kind of birth control are you or your husband or partner using now to keep from getting pregnant? Check ALL that apply

Tubes tied or blocked (female sterilization or Essure^®)

Vasectomy (male sterilization)

Birth control pills

Condoms

Shots or injections (Depo-Provera^®)

Contraceptive patch (OrthoEvra^®) or vaginal ring (NuvaRing^®)

IUD (including Mirena^®, ParaGard^®, Liletta^®, or Skyla^®)

Contraceptive implant in the arm (Nexplanon^® or Implanon^®)

Natural family planning (including rhythm method)

Withdrawal (pulling out)

Not having sex (abstinence)

Other  Please tell us: _____________________________

27. (CAPRZ Q30 - modified) How do you feel about having a child sometime in the future?

I do not want to have any more children

I would like to have another child in the next 1-2 years

I would like to have another child in the next 3-5 years

I would like to have another child after 5 or more years

I would like to have another child, but I’m not sure when

The last questions are about avoiding mosquito bites.

28. (ZPER 14 + ZPER 23) Since your new baby was born, are you doing any of the following things to avoid mosquito bites or control mosquitos in your home? For each one, check No if you did not do it or Yes if you did.

Yes No

1. Always use screens on open doors  

2. Always use screens on open windows  

3. Keep unscreened doors and windows closed  

4. Always use fans or air conditioning  

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

6. Sleep under a mosquito bed net  

7. Spray inside my home for mosquitos  

8. Spray outside or around my home and in my yard for mosquitos  

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

29. (ZPER 15) Since your new baby was born, how often do you use a mosquito repellent, on your exposed skin or clothing, when you went outside, even if you are only outside for a short time?

Every day

Most days

Some days

Never  Go to Question 31

30. (ZPER 16) Since your new baby was born ,when you use mosquito repellent on your exposed skin, how many times a day do you apply it?

More than once a day

Once a day

If you used mosquito repellent on your skin or clothing every day when outside, go to Question 32.

31. (ZPER 17) When you do not wear mosquito repellent, what are your reasons for not wearing it? Check ALL that apply

I do not like the way it smells or it makes me nauseous

I do not like the way it makes my skin feel

I have an allergy

I worry about the chemicals in the repellent harming me

Mosquito repellent was too expensive

I forget to apply it

I am not worried about getting Zika virus

I do not want to use it

Other reason  Please tell us: ______________________________________________

32. (ZPER 7 modified) How worried are you about getting infected with Zika virus now? Check ONE answer

Very worried

Somewhat worried

Not at all worried

The last questions are about testing for Zika virus.

33. (New) During any of the following time periods, were you tested for Zika virus infection? For each time period, check No if you were not tested then or Yes if you were.

No Yes

Before my most recent pregnancy

During the first 3 months of my pregnancy (1^st trimester)

During the middle 3 months of my pregnancy (2^nd trimester)

During the last 3 months of my pregnancy (3^rd trimester)

After my most recent pregnancy

If you did NOT receive a test for Zika virus infection at any time, go to Question 36.

34. (New) After you got tested for Zika, how long did you have to wait to receive the results? For each time period, check the amount of time you waited to receive the results (within one month, after one month, or you have still not received the results).

Within 1 month/ More than 1 month /Not received

Before my most recent pregnancy   

During the first 3 months of my pregnancy (1^st trimester)   

During the middle 3 months of my pregnancy (2^nd trimester)   

During the last 3 months of my pregnancy (3^rd trimester)   

After my most recent pregnancy   

35. (New) Where did you get tested for Zika virus? Check ALL that apply

Private doctor’s office

Hospital

Health department clinic or health center (330 Clinic or IPA)

Laboratory (private or commercial)

Other: __________________

If you WERE tested for Zika virus infection at any time, go to Question 37.

36. What is the reason that you did not receive a test for Zika virus before, during, or after your most recent pregnancy? For each item, check No if it was not a reason for you, or Yes if it was.

No Yes

1. I was not told to get tested or no one referred me

2. The testing locations were not easy to get to

3. The test was too expensive

4. I was afraid that my health insurance was not going to pay for the test

5. I was afraid of the result

6. I didn’t think Zika was a problem

7. I didn’t think I was at risk for Zika

8. Some other reason

Please tell us: _______________________________

(New) What was the longest you waited to receive your Zika test result after being tested?

Less than one month after being tested

More than one month after being tested

I haven’t received my test results

I don’t remember

(New) Aside from yourself, was anyone else in your home tested for Zika virus during your most recent pregnancy?

No

Yes

I don’t know

37. During your most recent pregnancy, did a doctor, nurse, or other healthcare worker tell you or anyone else who lives with you that they had Zika virus infection? For each person, please mark No if they were not told they had Zika virus during your pregnancy, or Yes if they were.

No Yes

1. Me

2. My husband or any male partner

3. Another person who lives with you

Please tell us who: ________________________

38. To thank you for participating in this survey, we would like to give you a small gift. Can you please tell me what address we should send it to?

_____________________________________________________________________

Thank you for answering these questions! Your answers will help us keep pregnant women and their babies healthy.