Zika Reproductive Health Call-Back Survey (ZRHCS), Puert

Attachment 4

Zika Reproductive Health Call-Back Survey

(ZRHCS), Puerto Rico, 2017

Survey and Consent

Public reporting burden of this collection of information is estimated to average 10 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx).

Contents

Introductory Script 3

Consent & screening 3

Zika-Related Knowledge and Behaviors 3

Sexual Transmission of Zika 7

Having Children and Contraception 8

Circumstances of Pregnancy 12

Zika-related reproductive behaviors 13

Closing Statement 14

Introductory Script: HELLO, I am calling for the ___(health department)___. My name is (name) . We are gathering information about the health of ___(state)___residents, specifically contraception and health practices related to the Zika virus. During a recent phone interview (sample person first name or initials) indicated she would be willing to participate in this survey. This project is conducted by the [STATE] Health Department with assistance from the Centers for Disease Control and Prevention.

1. Is this (phone number) ?

Yes

No-->[Confirm phone number] AND SAY: “Thank you very much, but I seem to have dialed the wrong number. It’s possible that your number may be called at a later time. END INTERVIEW

2. Are you (sample person first name or initials)?

Yes

No Ask if person is available. If not, schedule a time to call in the future.

Participation in this survey is voluntary. You may skip or refuse to answer any question. We will not ask you for any personal information, such as your name or address, and your responses will be confidential. The survey takes about 10 minutes to complete.

Consent & screening

3. Is this a good time to talk with you?

Yes

Nosay “Thank you very much. We will call you back at a more convenient time.” STOP

(SET APPOINTMENT IF POSSIBLE)

Zika-Related Knowledge and Behaviors

First I will ask a few questions to see what you already know about Zika.

1. At any time, has a doctor, nurse, or other healthcare worker talked to you about Zika?

DO NOT READ:

1 Yes

2 No  Go to Q3

7 Don’t Know/Not sure  Go to Q3

9 Refused  Go to Q3

2. Did you ask about Zika before that discussion?

DO NOT READ:

1 Yes

2 No

7 Don’t Know/Not sure

9 Refused

3. From what source have you received the most information about Zika virus?

[INTERVIEWER NOTE: IF RESPONDENT PROVIDES MORE THAN ONE ADD “WHICH SOURCE PROVIDED THE MOST INFORMATION TO YOU”]

DO NOT READ:

1 Healthcare worker (family doctor, OB/GYN, midwife, nurse, other medical professional)

2 Family or friends

3 The Centers for Disease Control and Prevention (CDC)

4 Health Department (either state or local)

5 Television

6 Radio

7 Social network sites like Facebook, Twitter, Instagram

8 Newspaper

9 Other website/internet

10 Some other source

11 Have not received information

77 Don’t Know/Not sure

99 Refused to answer

4. What source would you trust the most for receiving information about Zika virus?

[INTERVIEWER NOTE: IF RESPONDENT PROVIDES MORE THAN ONE ADD “WHICH SOURCE DO YOU TRUST THE MOST”]

READ:

1 Healthcare worker (for example, a family doctor, OB/GYN, midwife, nurse, other medical

professionals)

2 Family or friends

3 The Centers for Disease Control and Prevention (CDC)

4 Health Department (either ___state___ or local)

5 Television

6 Radio

7 Social network sites like Facebook, Twitter, Instagram

8 Newspaper

9 Other website/internet

DO NOT READ:

10 Some other source

77 Don’t Know/Not sure

99 Refused to answer

5. To the best of your knowledge, is Zika virus spread through the bite of an infected mosquito?

DO NOT READ:

1 Yes

2 No

7 Don’t Know/Not sure

9 Refused to answer

6. To the best of your knowledge, is Zika virus spread through coughing or sneezing?

DO NOT READ:

1 Yes

2 No

7 Don’t Know/Not sure

9 Refused to answer

7. To the best of your knowledge, is Zika virus spread through sex with an infected man?

DO NOT READ:

1 Yes

2 No

7 Don’t Know/Not sure

9 Refused to answer

8. To the best of your knowledge, is Zika virus spread through contaminated water?  

DO NOT READ:

1 Yes

2 No

7 Don’t Know/Not sure

9 Refused to answer

The following questions are about things you might do to avoid mosquito bites.

9. Do you keep unscreened doors and windows closed in your home?

DO NOT READ:

1 Yes

2 No

7 Don’t Know/Not sure

9 Refused to answer

10. Do you use fans or air conditioning in your home?

DO NOT READ:

1 Yes

2 No

7 Don’t Know/Not sure

9 Refused to answer

11. Do you, at least once a week, eliminate standing water in or around your house and yard?

DO NOT READ:

1 Yes

2 No

7 Don’t Know/Not sure

9 Refused to answer

12. How often do you sleep under a mosquito bed net?

READ:

1 Every day

2 Most days

3 Some days

4 Never

DO NOT READ:

7 Don’t Know/Not sure

9 Refused to answer

13. How often do you use mosquito repellent on your skin when you go outside?

READ:

1 Every dayGO TO Q19

2 Most days

3 Some days

4 Never

7 Don’t Know/Not sure GO TO Q19

9 Refused to answer GO TO Q19

The following questions are about reasons why people many not wear mosquito repellant. When you do not wear mosquito repellant is it because…

14. You do not like the way it smells?

DO NOT READ:

1 Yes

2 No

7 Don’t Know/Not sure

9 Refused to answer

15. You do not like the way it makes your skin feel?

DO NOT READ:

1 Yes

2 No

7 Not sure/Don’t know

9 Refused to answer

16. You worry about the chemicals in the repellent being harmful?

DO NOT READ:

1 Yes

2 No

7 Don’t Know/Not sure

9 Refused to answer

17. It is too expensive?

DO NOT READ:

1 Yes

2 No

7 Don’t Know/Not sure

9 Refused to answer

18. You forget to apply it?

DO NOT READ:

1 Yes

2 No

7 Don’t Know/Not sure

9 Refused to answer

19. During the past month, how often did you wear long sleeves and long pants when you went outside

READ:

1 Every dayGO TO Q21

2 Most days

3 Some days

4 Never

7 Don’t Know/Not sureGO TO Q21

9 Refused to answerGO TO Q21

20. When you did not wear long sleeves and long pants what was your main reason?

DO NOT READ:

1 I did not have (enough/many) clothes with long sleeves or long pants

2 It was too hot to wear long sleeves or long pants

3 I don’t like to wear long sleeves or long pants

4 Other reason

7 Don’t Know/Not sure

9 Refused to answer

21. During the last 3 months, did you receive professional indoor spraying of your home for mosquito control?

DO NOT READ:

1 Yes

2 No

7 Don’t Know/Not sure

9 Refused to answer

22. During the last 3 months, did you receive professional outdoor spraying around your house or in your yard for mosquito control?

DO NOT READ:

1 Yes

2 No

3 Not Applicable (does not have outdoor area)

7 Don’t Know/Not sure

9 Refused to answer

Sexual Transmission of Zika

The next questions are about behaviors related to sexual transmission of Zika and current and previous pregnancies. You may refuse to answer any question that you are not comfortable with. Please remember that all your answers are confidential.

23. About how long has it been since you last had sexual intercourse with a man?

DO NOT READ:

1 Less than 3 months

2 3 months to less than 6 months GO TO Q26

3 6 months to one year  GO TO Q26

4 More than a year  GO TO Q26

5 Never had sexual intercourse with a man  GO TO Q26

7 Don’t Know/Not sure  GO TO Q26

9 Refuse to answer GO TO Q26

24. When you had sex with a man during the last 3 months, how often did you and your partner use a condom? Was it…

READ:

1 Every time, GO TO Q26

2 Most of the time,

3 Some of the time, or

4 Not at all?

DO NOT READ:

7 Don’t Know/Not sureGO TO Q26

9 Refused to answerGO TO Q26

25. What was your most important reason for not using condoms every time you had sex with a man during the last 3 months?

[INTERVIEWER NOTE: IF RESPONDENT PROVIDES MORE THAN ONE ADD “WHICH REASON WAS THE MOST IMPORTANT?”]

DO NOT READ:

1 Want to get pregnant

2 Don’t care if get pregnant

3 Was pregnant

4 Didn’t think about it/Forgot/In a hurry

5 Don’t like condoms

6 Already using another contraceptive method this includes vasectomy and sterilization

7 In a committed relationship

8 Partner objects

9 Religious reasons

10 Couldn’t pay for condoms

11 Had a problem getting condoms when needed/ No condoms available

12 Menopause/ Infertile

13 Had a hysterectomy

14 Don’t think I can get pregnant

15 Was breastfeeding

16 Recently had a baby/Postpartum

17 Forced to have sex

18 Under the influence of alcohol or drugs

19 Other reason – please specify

____________________________________

77 Don’t Know/Not sure

99 Refused to answer

Having Children and Contraception

26. Are you currently pregnant?

DO NOT READ:

1 Yes

2 No

7 Don’t Know/Not sure

9 Refused to answer

27. How do you feel about having a [“another” for pregnant women] child now or sometime in the future? Would you say:

READ:

1 You don’t want to have one/another

2 You want to have one, less than 12 months from now

3 You want to have one, between 1 and 2 years from now

4 You want to have one, between 2 and 5 years from now

5 You want to have one, at least 5 years from now

6 You want to have one, but not sure when

7 Not sure if want to have any/another

DO NOT READ:

9 Refused to answer

PROGRAMMER NOTE: IF CURRENTLY PREGNANT (Q26 = 1) AND/OR NEVER HAD SEX WITH A MAN (Q23=5) GO TO Q37

28. Are you or your male partner doing anything or using anything to keep you from getting pregnant?

[INTERVIEWER NOTE: THIS INCLUDES ANYTHING THE RESPONDENT IS DOING, SUCH AS STERILIZATION, VASECTOMY, IUD OR INJECTIONS]

DO NOT READ:

1 Yes

2 No

7 Don’t Know/Not sure

9 Refused to answer

29. Have you had an operation to tie or block your tubes (for example Essure or Adiana) so that you cannot get pregnant or has your male partner had a vasectomy?

[INTERVIEWER NOTE: IF RESPONDENT REPORTS BOTH SHE AND HER PARTNER HAVE BEEN STERILIZED THEN SELECT 1 YES, FEMALE STERILIZATION]

DO NOT READ:

1 Yes, Female Sterilization GO TO Q32

2 Yes, my male partner has had a vasectomy GO TO Q32

3 No

7 Don’t Know/Not sure

9 Refused to answer

PROGRAMMER NOTE: IF Q28=NO (2) AND Q29=NO (3) THEN SKIP TO Q34

30. What are you or your partner using or doing to keep you from getting pregnant?

[ INTERVIEWER NOTE: IF MORE THAN 1 METHOD MENTIONED, ENTER THE ONE WITH THE LOWEST RESPONSE NUMBER]

DO NOT READ:

1 Contraceptive implant (Nexplanon, Jadelle, Sino Implant, Implanon) Go to Q32

2 IUD (for example, ParaGard, Mirena, Skyla, Liletta)

3 Shots/Injections (for example, Depo-Provera) Go to Q32

4 Birth control pills (daily pills, any kind) Go to Q32

5 Contraceptive patch (Ortho Evra, Xulane) Go to Q32

6 Contraceptive ring (NuvaRing) Go to Q32

7 Male condoms Go to Q32

8 Diaphragm Go to Q32

9 Female condoms Go to Q32

10 Foam, jelly, film, or cream Go to Q32

11 Emergency contraception (morning after pill) Go to Q32

12 Not having sex at certain times (rhythm or natural family planning) Go to Q32

13 Withdrawal (pulling out) Go to Q32

14 Other method___________________________________________Go to Q32

77 Don’t Know /Not sure Go to Q35

99 Refused to answer Go to Q35

31. What type of IUD do you have?

READ:

1 Copper IUD (ParaGard)

2 Hormonal IUD (Mirena, Skyla, Liletta)

DO NOT READ:

7 Don’t Know/Not sure

9 Refused to answer

32. As best you can remember, since what month and year did you start using that method of contraception?

Month ___ ___ Year  ___ ___ ___ ___  [ PROGRAMMING NOTE: If month/year started new method after January 2016 go to Q33, otherwise go to Q36]

77/7777 Don’t Know/Not sure go to Q36

99/9999 Refused to answer go to Q36

33. What was your most important reason for starting that method?

DO NOT READ:

1 Recently got insuranceGO TO Q36

2 Lost health insurance/couldn’t pay for method I was usingGO TO Q36

3 Didn’t like the method I was usingGO TO Q36

4 In a new relationshipGO TO Q36

5 Recently became sexually activeGO TO Q36

6 Concerned about ZikaGO TO Q36

7 Other health reasonsGO TO Q36

8 Recently had a babyGO TO Q36

77 Don’t Know/Not sure GO TO Q36

99 Refused to answerGO TO Q36

34. What is the most important reason for not doing anything to keep you from getting pregnant?

[INTERVIEWER NOTE: IF RESPONDENT PROVIDES MORE THAN ONE ADD “WHICH REASON WAS THE MOST IMPORTANT REASON?”]

DO NOT READ:

1 Want to get pregnant

2 Don’t care if get pregnant

3 Haven’t thought about using anything/Forgot/in an hurry

4 Can’t find a method I like

5 Partner objects

6 Worry about side effects

7 Religious reasons

8 Can’t pay for contraception

9 Have a problem getting contraception when needed

10 Menopause

11 Have not gotten pregnant in over 2 years without using contraception

12 Had a hysterectomyGO TO Q37

13 Don’t think I can get pregnant

14 Was breastfeeding

15 Recently had a baby/Postpartum

16 No male partner/not sexually active

17 Other reason

77 Don’t Know/Not sure

99 Refused to answer

35. If you did not have to worry about cost and could use any type of contraceptive method available, would you want to use a method?

DO NOT READ:

1 YesGO TO Q37

2 NoGO TO Q37

7 Don’t Know/Not sure GO TO Q37

9 Refused to answerGO TO Q37

36. If you did not have to worry about cost and could use any type of contraceptive method available, would you want to use a different method?

DO NOT READ:

1 Yes

2 No

7 Don’t Know/Not sure

9 Refused to answer

37. Have you ever been pregnant, including pregnancies that ended in miscarriage or abortion?

[PROGRAMMING NOTE: IF CURRENTLY PREGNANT ASK “HAVE YOU EVER BEEN PREGNANT BEFORE YOUR CURRENT PREGNANCY, INCLUDING PREGNANCIES THAT ENDED IN MISCARRIAGE OR ABORTION?”]

1 Yes

2 No IF Q26=1 AND Q23 NOT 5, GO TO INSTRUCTIONS BEFORE Q40. IF Q26=1 AND Q23=5, GO TO Q437. IF Q26 NOT 1, GO TO Q43

7 Don’t Know/Not sure IF Q26=1 AND Q23 NOT 5, GO TO INSTRUCTIONS BEFORE Q40. IF Q26=1 AND Q23=5, GO TO Q43. IF Q26 NOT 1, GO TO Q43

9 Refused to answer  IF Q26=1 AND Q23 NOT 5, GO TO INSTRUCTIONS BEFORE Q40. IF Q26=1 AND Q23=5, GO TO Q43. IF Q26 NOT 1, GO TO Q43

38. In what month and year did your most recent pregnancy end?

MONTH: __ __ YEAR: __ __ __ __

77/7777 Don’t Know/Not sure

99/9999 Refused to answer

39. How many children have you given birth to who are still alive, including any who do not live with you?

___ ___ Children

77 Don’t know/Not sure

88 None

99 Refused

PROGRAMMER NOTE: IF NEVER HAD SEX WITH A MAN (Q23=5) GO TO Q43

Circumstances of Pregnancy

IF RESPONDENT IS CURRENTLY PREGNANT [Q26=1], SAY: The next questions ask about your circumstances and feelings around the time you became pregnant for your current pregnancy. Please think of your current pregnancy when answering the next questions.

IF RESPONDENT IS NOT CURRENTLY PREGNANT, SAY: The next questions ask about your circumstances and feelings around the time you became pregnant. Please think of your most recent pregnancy when answering the next questions.

40. Right before you got pregnant, were you or your male partner doing anything or using anything to keep from getting pregnant?

[INTERVIEWER NOTE: THIS INCLUDES THINGS LIKE STERILIZATION, VASECTOMY, AN IUD OR INJECTIONS.]

1 Yes

2 No GO TO Q43

7 Don’t know/Not sure GO TO Q42

9 Refused GO TO Q43

41. What did you or male partner use or do to keep you from getting pregnant?

DO NOT READ:

[INTERVIEWER NOTE: IF MORE THAN 1 REASON GIVEN, ENTER THE ONE WITH THE LOWEST RESPONSE NUMBER]

1 Female sterilization (tubal ligation, tubes tied, Essure, Adiana)

2 Male sterilization (vasectomy)

3 Contraceptive implant (Nexplanon, Jadelle, Sino Implant, Implanon)

4 IUD (ParaGard, Mirena, Skyla, Liletta)

5 Shots/Injections (for example, Depo-Provera)

6 Birth control pills (daily pills, any kind)

7 Contraceptive patch (Ortho Evra, Xulane)

8 Contraceptive ring (NuvaRing)

9 Male condoms

10 Diaphragm

11 Female condoms

12 Foam, jelly, film, or cream

13 Emergency contraception (morning after pill)

14 Not having sex at certain times (rhythm or natural family planning)

15 Withdrawal (pulling out)

16 Other method

77 Don’t know/Not sure

99 Refused

42. Thinking back to just before you got pregnant, how did you feel about becoming pregnant? You…

READ:

1 Wanted to be pregnant later

2 Wanted to be pregnant sooner

3 Wanted to be pregnant at that time

4 Didn’t want to be pregnant then or at any time in the future, or

5 Were not sure about what you wanted

DO NOT READ:

7 Don’t know/Not sure

9 Refused

Zika-related reproductive behaviors

43. How worried are you about getting infected with the Zika virus? Are you…

READ:

1 Very worried,

2 Somewhat worried,

3 A little worried, or

4 Not worried at all

DO NOT READ:

5 Already had Zika virus

7 Don’t Know/Not sure

9 Refused

PROGRAMMER NOTE: IF PERMANENTLY UNABLE TO BECOME PREGNANT (HAD A HYSTERECTOMY, MENOPAUSAL, OR INFERTILE: Q23=12 OR 13 OR Q34=10, 11 OR 12) END QUESTIONNAIRE AND GO TO CLOSING STATEMENT.

44. How worried are you about having a child with microcephaly or another birth defect linked to Zika? Are you…

READ:

1 Very worried

2 Somewhat worried

3 A little worried, or

4 Not worried at all

DO NOT READ:

5 I have never heard of a link between Zika and birth defects

7 Don’t know/Not sure

9 Refused to answer

45. Have you changed your plans about whether or when to have (more) children because of Zika?

DO NOT READ:

1 Yes

2 NoGO TO Q47

7 Don’t know/Not Sure GO TO Q47

9 Refused to answerGO TO Q47

46. How have you changed your plans? Have you:

READ:

1 Decided to wait longer to become pregnant

2 Decided to have no more children

3 Decided not to get pregnant soon, but have not made long-term plans yet

DO NOT READ:

4 Other ______________________________________________________

7 Don’t know/Not Sure

9 Refused to answer

47. Have you changed your contraceptive use because of Zika?

DO NOT READ:

1 Yes: Started using a method

2 Yes: Switched to a more effective method

3 Yes: More consistent in using contraceptive method

4 Yes: Using condoms in addition to my usual contraceptive method

5 Yes: Other

6 No change

7 Don’t know/ Not sure

9 Refused to answer

Closing Statement

That was my last question. Everyone’s answers will be combined to help us provide information about contraception and health practices related to the Zika virus. Thank you very much for your time and cooperation

Last modified: 3/7/2017

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