IN-HOSPITAL PARTNER SURVEY: English version

PRAMS ZPER 2.0 – IN-HOSPITAL PARTNER SURVEY: English version

Form Approved

OMB No.0920-XXXX

Exp. Date xx/xx/20xx

Public reporting burden of this collection of information is estimated to average 15 minutes, 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).

English

PRAMS-ZPER 2.0 In-Hospital Partner Survey (English)

We would like to learn about your experiences over the past year. First, we would like to ask a few questions about you.

1. What is your date of birth?

MONTH/DAY/YEAR

2. In which 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.)

Name of the municipality: _____________________________

_____ I am not currently living in Puerto Rico

3. What is the highest level of education that you have completed?

Less than high school diploma

High school diploma or General Education Diploma (GED)

Some college or technical school

Completed college

Some graduate school

Completed graduate school (masters or doctorate degree)

4. In the past 12 months, what kind of health insurance did you have? (Check all that apply.)

I did not have health insurance of any kind

Private health insurance from my job or the job of my wife or partner

Private health insurance from my parents

Private health insurance that I paid for myself or that someone else paid for me

Government health insurance/Medicaid (also known as Mi Salud or Reforma)

Other  Please, tell us: _________________________________

The following questions are about Zika virus.

5. In the past 12 months, how worried were you about getting infected with Zika virus? (Check one answer.)

Very worried

Somewhat worried

Not at all worried

6. Which ONE of these sources do you trust the most for receiving information about Zika virus? (Check one answer.)

Healthcare worker (for example, a family doctor, other medical professionals)

My wife or partner

Family or friends

The Centers for Disease Control and Prevention (CDC)

The Puerto Rico Department of Health

Television or radio news

Social network sites like Facebook

Other websites  Please tell us which ones: ________________

Some other source  Please tell us: ___________________

7. In your opinion, which of the following statements about Zika virus are true and which are false? (For each one, check True if you think it is correct or False, if you do not.)

True False

1. Zika virus can be spread by having sex with someone who has Zika  

2. Zika virus infection during pregnancy can cause birth defects in the baby  

3. Zika virus can be spread by the bite of a mosquito  

4. Zika virus can be found in semen up to 6 months after a man is infected  

5. Everyone who gets Zika has symptoms  

8. In the past 12 months, did you have any health care visits for yourself with a doctor, nurse, or other health care worker?

Yes

No  Go to Question 11

9. What type of health care visits did you have in the past 12 months? (Check all that apply.)

Regular checkup at my family doctor’s office

Visit for Zika virus

Visit for an illness or chronic condition

Visit for an injury

Visit for depression or anxiety

Visit to have my teeth cleaned by a dentist or dental hygienist

Other  Please tell us: _______________________________

10. During any of your health care visits in the past 12 months, did a doctor, nurse, or other health care worker do any of the following things? (For each item, check Yes if they did it or No, if they did not.) Yes No

1. Talked to you about the importance of preventing Zika virus infection  

2. Talked to you about preventing mosquito bites  

3. Talked to you about condom use to prevent Zika  

4. Talked to you about my desire to have or not have children  

5. Talked to you about ways to prevent pregnancy  

6. Talked to you about sexually transmitted infections such as chlamydia,
   gonorrhea, syphilis or HIV  

7. Talked to you about maintaining a healthy weight  

8. Talked to you about controlling any medical conditions such as diabetes
   or high blood pressure  

9. Asked you if you were smoking cigarettes  

10. Asked you if you were feeling down or depressed  

11. Asked you about the kind of work you do  

11. In the past 12 months, did you ever have symptoms of Zika virus infection such as fever, rash, head ache, joint pain, red eyes, or muscle pain?

Yes

No

12. In the past 12 months, were you tested for Zika virus?

Yes

No

13. During any of the following time periods, did a doctor, nurse or other healthcare worker tell you that you had Zika virus infection? (For each time period, check Yes if you were told you had Zika virus then or No if you were not. You can ask or use a calendar.)

Yes No

1. In the past 30 days  

2. In the past 1 to 3 months  

3. In the past 4 to 6 months  

4. In the past 7 to 9 months  

5. In the past 10 to 12 months  

The following questions are about avoiding mosquito bites.

14. In the past 12 months, did you do any of the following things to avoid mosquito bites in your home? (For each one, check Yes if you did it or No if you did not.)

Yes No

1. Always used screens on open doors  

2. Always used screens on open windows  

3. Always kept unscreened doors and windows closed  

4. Always used fans or air conditioning  

5. Eliminated standing water from your house and yard on a weekly basis  

6. Slept under a mosquito bed net  

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

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

9. Applied larvicides around the outside of your home  

10. Set-up mosquito traps  

15. In the past 12 months, how often did you use a mosquito repellent on your exposed skin or clothing when you went outside, even if you were only outside for a short time? (Check one answer.)

Always

Sometimes

Rarely or when I saw mosquitos

Never  Go to question 17

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

More than once a day
Once a day

17. When you did not wear mosquito repellent, 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

I worried about the chemicals in the repellent would harm my partner

I forgot to apply it

I had an allergy or it made my skin itch

I didn’t think I needed it

I was rarely outside

Mosquito repellent was too expensive

My wife or partner didn’t like it when I used it

Other reason  Please, tell us: _____________________________

The next questions are about contraception.

1. What method of birth control are you planning to use after your wife’s or partner’s pregnancy? (Check all that apply.)

Condoms

Vasectomy

Withdrawal (Pull-out method)

Natural Family Planning (including rhythm method)

My wife or partner will use the birth control pill

My wife or partner will get the contraceptive shots (Depo)

My wife or partner will use the patch or vaginal ring

My wife or partner will get a contraceptive implant in the arm

My wife or partner will get an IUD

My wife or partner will have her tubes tied (female sterilization)

Other method  Please tell us: _________________________

I don’t know

My partner and I won’t use contraception Go to Question 20

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

It is easy to use

It is easy to get

It interferes least with sex

It is affordable

It has fewer side effects

It works well to prevent pregnancy

It prevents sexually transmitted diseases (STD’s)/HIV

My female partner recommends it

My physician recommends it

My friends recommend it

Other  Please specify: _________________________

The following questions are about the pregnancy of the mother of your new baby.

19. When she got pregnant, what relationship did you have with the mother of your new baby? (Check one answer.)

She was my wife (legally married)

She was my partner (not legally married, but a long-term partner)

She was my girlfriend (a casual partner)

Other  Please explain: ________________________

19. Did you live with the mother of your new baby during her pregnancy? (Check one answer.)

Yes, for the entire pregnancy

Yes, for part of the pregnancy

No

19. Thinking back to just before the mother of your new baby got pregnant, which ONE of the following statements best describes how you felt about having a baby? (Check one answer.)

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

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

I wanted to have a baby sooner

I wanted to have a baby then

I never wanted to have a baby

I wasn’t sure what I wanted

19. How worried were you about the mother of your new baby getting infected with Zika virus while she was pregnant? (Check one answer.)

Very worried

Somewhat worried

Not at all worried

19. During the pregnancy of the mother of 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.) (Check one answer.)

Very worried

Somewhat worried

Not at all worried

19. During her pregnancy, did you talk with the mother of your new baby about Zika virus?

Yes

No  Go to Question 27

19. When you spoke with the mother of your new baby about Zika during her pregnancy, did you talk about any of the following topics? (For each one, check Yes if you talked about the topic, or No if you did not.)

Yes No

1. The risk of having a baby with birth defects that are associated with Zika  

2. Protecting the home from mosquitoes  

3. Using mosquito repellent to avoid mosquito bites  

4. Abstaining from sex to avoid Zika infection  

5. Using condoms during sex to avoid Zika virus transmission  

19. Did you go with the mother of your new baby to her prenatal care visits? (Check one answer.)

Yes, I went to all of the prenatal care visits

Yes, I went to some of the prenatal care visits

No  Go to Question 29

19. During any of the prenatal care visits, did a doctor, nurse, or other healthcare worker talk with you about ways that you could help the mother of your new baby avoid Zika virus infection during her pregnancy?

Yes

No

If you went to all the prenatal care visits with the mother of your new baby, go to Question 30.

19. What were your reasons for not going to all of the prenatal care visits with the mother of your new baby? (Check all that apply.)

I couldn’t take time off from work or school

The appointment times were not convenient for me

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

I had too many other things going on

I didn’t think I needed to go

I didn’t think I would get useful information at these visits

My wife or partner didn’t want me to

I didn’t want to go

The mother of my new baby did not go for prenatal care

Other reason  Please, explain your reason: _____________________

19. Did you have sex with the mother of your new baby at any of the following times during her pregnancy? (You can ask or use a calendar.)

Yes No, to avoid Zika No, for another reason

1. Months 1 to 3   

2. Months 4 to 6   

3. Months 7 to 9   

If you did not have sex with the mother of your new baby during her pregnancy, go to Question 33.

19. How often did you use a condom when you had sex with the mother of your new baby at any of the following times during her pregnancy?

Every time Sometimes Never

1. Months 1 to 3   

2. Months 4 to 6   

3. Months 7 to 9   

If you used a condom every time you had sex with the mother of your new baby during her pregnancy, go to Question 33. If not, go to Question 32.

19. What were your reasons for not using condoms every time when having sex with the mother of your new baby during her pregnancy? (Check all that apply.)

I didn’t know she was pregnant

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

I didn’t think a condom would prevent Zika infection

I didn’t think Zika was still a problem

I didn’t think I had Zika virus

I didn’t want to use condoms

She 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

My partner or I had an allergy

Other reason  Please, tell us: ______________________________

19. Did you attend the birth of your new baby?

Yes Go to Question 35

No

19. What were your reasons for not attending the birth of your new baby? (Check all that apply.)

I was out of town

The birth happened unexpectedly, and I couldn’t get there in time

I couldn’t take time off from work or school

I had no one to take care of my other children

My wife or partner didn’t want me to attend

I didn’t want to attend

The medical staff did not allow me to attend

Other reason  Please tell us:_______________________

19. Have you done any of the following things to prepare for your new baby? (For each thing, check Yes if you have done it to prepare for your new baby or No if you have not.)

Yes No

1. Attend childbirth class or classes with the mother of my new baby  

2. Attend breastfeeding class or classes with the mother of my new baby 

3. Look up information about pregnancy and birth on the Internet

or in other places  

4. Talk with the mother of my new baby about pregnancy, birth and
   caring for a new baby  

5. Talk with family or friends about pregnancy, birth and caring for
   a new baby  

6. Purchase baby supplies such as crib, stroller, clothing, diapers,
   bottles, blankets, car seat, etc.  

7. Make repairs or improvements to the home to keep mosquitos out  

8. Prepare the home for the new baby by setting up a space for the baby  

9. Improve my health by dieting (changing my eating habits) to lose weight  

10. Improve my health by exercising 3 or more days of the week  

11. Seek help for health conditions such as depression or anxiety  

12. Seek help to reduce my cigarette, alcohol or drug use  

19. Did you feel like you were as involved as you wanted to be in the pregnancy of the mother of your new baby? (Check one answer.)

Yes

No, I wanted to be more involved

No, I wanted to be less involved

19. This question asks about concerns and feelings you may have about becoming a father. (For each item, check Yes if it describes you or No if it does not.)

Yes No

1. I don’t feel like I am ready to be a father  

2. I am worried that I don’t know enough

about how to take care of a baby  

3. I think a new baby will keep me from doing

the things I am used to doing, like working,

going to school, or going out  

4. I look forward to teaching and caring for a

new baby  

5. I look forward to the new experiences that

having a baby will bring  

6. I look forward to telling my friends about the baby  

7. I worry that I do not have enough money to

take care of a baby  

8. I worry about balancing work and family  

9. I worry about having a healthy baby  

19. In the past 12 months, how often have you felt down, depressed, or hopeless? (Check one answer.)

Always

Often

Sometimes

Rarely

Never

19. In the past 12 months, how often have you had little interest or little pleasure in doing things you usually enjoyed? (Check one answer.)

Always

Often

Sometimes

Rarely

Never

19. Are your currently working at a job for pay? (Check all that apply.)

Yes, I have a part-time job (30 hours or less a week)

Yes, I have a full-time job ( More than 30 hours a week)

No  Go to Question 42

19. Once your baby is released from the hospital, will you take time off from work to care for your new baby? (Check all that apply.)

Yes, I will take paid leave or vacation from my job

Yes, I will take unpaid leave from my job

No, I will not take any leave

19. Will you be living with your new baby? (Check one answer.)

Yes, all the time

Yes, part of the time

No

I don’t know

19. Aside from your new baby, do you have any other children (biological or adopted)?

Yes

No  Go to end

19. Not including your new baby, how many children do you have (biological or adopted)?

__________ Number of children

Thank you very much for answering our questions!

Your answers will help us keep families in Puerto Rico healthy.

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