ZPER Telephone Follow-up Questionnaire – English phone v

ZPER Telephone Follow-up Questionnaire – English phone 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).

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

1. 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 to 6 weeks after she gives birth.

(Don’t read) 1 No

2 Yes  Go to Question 3

8 Refused  Go to Question 4

9 Don’t know/don’t remember  Go to Question 4

2. I’m going to read a list of reasons why some women may not have a postpartum checkup. For each one, please tell me if it was a reason for you. Would you say that you did not have a postpartum checkup because_________?

		(Don’t read)
	Reason	No (1)	Yes (2)	Refused (8)	Don’t know (9)
a.	You didn’t have health insurance to cover the cost of the visit
b.	You felt fine and did not think you needed to have a visit
c.	You couldn’t get an appointment when you wanted one
d.	You didn’t have any transportation to get to the clinic or doctor’s office
e.	You had too many things going on
f.	You couldn’t take time off from work
g.	Did you have some other reason?
h.	IF YES, ASK: What kept you from having a postpartum checkup? ________________________________________________________________________________________________________________________________________________________________________

INTERVIEWER: If the respondent did not have a postpartum check-up, go to Question 4.

3. During your postpartum checkup, did your doctor, nurse, or other health care worker do any of the following things? I am going to read a list of things. Did they __________?

(PROBE: Did a doctor, nurse, or other health care worker ______?)

Subject	(Don’t read)
	No (1)	Yes (2)	Refused (8)	Don’t know (9)
Talk to you about clothes to wear to prevent mosquito bites
Talk to you about using mosquito repellent on your skin or clothing
Talk to you about using condoms during sex to prevent Zika infection
Talk to you about birth control methods you can use after giving birth
Give or prescribe you a contraceptive method such as the pill, patch, shot or Depo-Provera®, NuvaRing®, or condoms
Insert an IUD such as Mirena®, ParaGard®, Liletta®, or Skyla® or a contraceptive implant such as Nexplanon® or Implanon®

4. I’m going to read a list of health conditions. For each one, please tell me if a doctor, nurse or other health care worker told you that you have the condition since your new baby was born. Have you been told that you have ______?

(PROBE: Since your new baby was born, has a doctor, nurse or other health care worker told you that you had ______?)

Condition	(Don’t read)
	No (1)	Yes (2)	Refused (8)	Don’t know (9)
Diabetes
High blood pressure or hypertension
Depression
Anxiety
Zika virus infection

5. I’m going to read a list of services some women receive after they have a baby. For each one, please tell me if you have received the service since your new baby was born.

(PROBE: Since your new baby was born, have you received services from________?)

		(Don’t read)
	List of Services	No (1)	Yes (2)	Refused (8)	Don’t know (9)
a.	Counseling for depression or anxiety
b.	WIC or the Special Supplemental Nutrition Program for Women, Infants, and Children
c.	The Home Visiting Program
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 adolescent 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. Is your baby alive now?

(Don’t read) 1 No → INTERVIEWER: “We are very sorry for your loss.” and Go to Question 24

2 Yes

8 Refused → Go to Question 24

9 Don’t know/don’t remember → Go to Question 24

7. Is your baby living with you now?

(Don’t read) 1 No → Go to Question 24

2 Yes

8 Refused → Go to Question 24

9 Don’t know/don’t remember → Go to Question 24

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

(Don’t read) 1 No → Go to Question 11

2 Yes

8 Refused → Go to Question 11

9 Don’t know/don’t remember → Go to Question 11

9. Are you currently breastfeeding or feeding pumped milk to your new baby?

(Don’t read) 1 No

2 Yes → Go to Question 11

8 Refused → Go to Question 11

9 Don’t know/don’t remember → Go to Question 11

10. How many weeks or months did you breastfeed or pump milk to feed your baby?

(PROBE: About how many weeks or months?)

(Don’t read) 1 Less than 1 week

2 Number of weeks_______ (Range: 1-40)

OR

3 Number of months ______ (Range: 1-9)

8 88 Refused

9 99 Don’t know/don’t remember

11. Has your new baby had any health care visits with a doctor, nurse, or other health care worker since you left the hospital where your baby was born? A health care visit can include a regular checkup or a visit for a health problem, illness or injury.

(Don’t read) 1 No

2 Yes  Go to Question 13

8 Refused  Go to Question 15

9 Don’t know/don’t remember  Go to Question 15

12. I’m going to read a list of things that can keep babies from having a health care visit. For each one, please tell me if it applied to you or your new baby.

(PROBE: Would you say that your baby did not get a health care visit because ________)

		(Don’t read)
	Reason	No (1)	Yes (2)	Refused (8)	Don’t know (9)
a.	You don’t have health insurance for your baby
b.	You don’t have enough money to pay for the visit
c.	You don’t have a way to get your baby to the clinic or doctor’s office
d.	You don’t have anyone to take care of your other children
e.	You can’t get an appointment
f.	You don’t think your new baby needs a health care visit
g.	Did anything else keep your baby from having a health care visit?
	IF YES, ASK:     What else kept your baby from having a health care visit? _____________________________________________________________________________________ _____________________________________________________________________________________

INTERVIEWER: If the baby has never had a health care visit after leaving the hospital, got to Question 15.

13. 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.

(PROBE: How many times has your baby had a health care visit? You can use a calendar.)

(Don’t read) _____ Times

88 Refused

99 Don’t know/don’t remember

14. Please tell me which one of the following best describes where you usually take your new baby for health care visits? Is it ________?

(PROBE: Where do you usually take your baby for his or her health care visits?)

1 A private doctor’s office

2 A Health Department Clinic such as a IPA Clinic

3 A Community Health Center such as a 330 Clinic

4 The Regional Pediatric Center

5 The Hospital Emergency Room

6 A Hospital Outpatient Clinic

7 Do you take your baby to some other place?

 IF YES, ASK:    Where else do you usually take your baby for his or her health care visits? ___________

(Don’t read) 8 Refused

9. Don’t know/don’t remember

15. 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.

(PROBE: Does your baby have one or more people you consider their personal doctor or nurse?)

1 No

2 Yes, one person

3 Yes, more than one person

(Don’t read) 8 Refused

9. Don’t know/don’t remember

16. Since your new baby was born, has a doctor, nurse, or other health care worker talked with you about any of the following things? I am going to read a short list. For each topic, please tell me if they talked to you about it or not.

(PROBE: Did a doctor, nurse, or other health care worker talk to you about __________?)

Topic	(Don’t read)
	No (1)	Yes (2)	Refused (8)	Don’t know (9)
Dressing your baby in long sleeves and long pants to avoid mosquito bites
Using mosquito repellent on your baby’s exposed skin or clothing
Putting a mosquito net over your baby’s crib or bed
What the signs and symptoms of Zika virus infection are in a baby

17. Since your new baby was born, has a doctor, nurse, or other health care worker told you that your new baby was infected with Zika virus during your pregnancy?

(Don’t read) 1 No

2 Yes  Go to Question 19

8 Refused  Go to Question 18

9. Don’t know/don’t remember  Go to Question 18

18. How worried are you about your new baby getting infected with Zika virus now? Would you say very worried, somewhat worried, or not at all worried?

(PROBE: Repeat question as necessary.)

(Don’t read)

1 Very worried

2 Somewhat worried

3 Not at all worried

8 Refused

9. Don’t know/don’t remember

19. I’m going to read a list of health conditions. For each one, please tell me if your new baby has the condition. Does your baby have ___________?

	Condition	No (1)	Yes (2)	Refused (8)	Don’t know (9)
a.	Hearing problems
b.	Vision problems
c.	Poor weight gain
d.	Difficulties feeding
e.	Smaller than normal head size
f.	Muscle weakness
g.	Deformity of the feet
h.	Convulsions

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

20. 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?

(Don’t read) 1 No

2 Yes

8 Refused

9. Don’t know/don’t remember

21. 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?

(Don’t read) 1 No

2 Yes

8 Refused

9. Don’t know/don’t remember

22. I’m going to read a list of services some babies receive. For each one, please tell me if your new baby received the service. Has your new baby received _______________ ?

	Reasons	No (1)	Yes (2)	Refused (8)	Don’t know (9)
a.	A scan or ultrasound of his or her 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. 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?

(Don’t read) 1 No

2 Yes

8 Refused

9 Don’t know/don’t remember

The next questions are about the use of contraception.

24. 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.

(Don’t read) 1 No

2 Yes → Go to Question 26

8 Refused → Go to Question 27

9 Don’t know/don’t remember → Go to Question 27

25. I’m going to read a list of reasons some women or their husbands or partners have for not doing anything to keep from getting pregnant. For each one, please tell me if it is one of the reasons for you or your husband or partner now. Is it because______?

(PROBE: You aren’t doing anything to keep from getting pregnant now because______?)

Reason	(Don’t read)
	No (1)	Yes (2)	Refused (8)	Don’t know (9)
You want to get pregnant
You are pregnant now
You had your tubes tied or blocked
You don’t want to use birth control
You are worried about side effects from birth control
You are not having sex
Your husband or partner doesn’t want to use anything
You have problems paying for birth control
Is there any other reason you’re not doing anything to keep from getting pregnant now?
IF YES, ASK: What is the reason you are not doing anything to keep from getting pregnant now? _________________________________________________________________________ _________________________________________________________________________

INTERVIEWER: If the respondent or her husband or partner is not doing anything to keep from getting pregnant now, go to Question 27.

INTERVIEWER: If the respondent is pregnant now, go to Question 28.

26. I’m going to read a list of birth control methods. For each one, please tell me if you or your husband or partner is using this method now.

(PROBE: What are you or your husband or partner using now to keep from getting pregnant?)

Method	(Don’t read)
	No (1)	Yes (2)	Refused (8)	Don’t know (9)
Tubes tied or blocked, female sterilization, or Essure®
Vasectomy or male sterilization
Birth control pills
Condoms
Shots, injections or Depo-Provera®
Contraceptive patch or OrthoEvra® or vaginal ring or NuvaRing®
IUD, including Mirena® or ParaGard®, Liletta®, or Skyla®
Contraceptive implant in the arm, including Nexplanon® or Implanon®
Natural family planning including rhythm method
Withdrawal or pulling out
Not having sex or abstinence
Are you or your husband or partner using anything else to keep from getting pregnant now?
IF YES, ASK: What other birth control method are you or your husband or partner using now to keep from getting pregnant? _________________________________________________________________________ _________________________________________________________________________________________________________________________________________________

27. How do you feel about having a child sometime in the future?

(PROBE: Would you say that ____________?)

	(1)	You do not want to have any more children
	(2)	You would like to have another child in the next 1-2 years
	(3)	You would like to have another child in the next 3-5 years
	(4)	You would like to have another child after 5 or more years
	(5)	You would like to have another child, but you are not sure when
Don’t Read	(8)	Refused
	(9)	Don’t Know / Don’t Remember

The next questions are about avoiding mosquito bites.

28. I’m going to read a list of things that some people do around their home to avoid mosquito bites or control mosquitos. For each one, please tell me if you do this around your home since your new baby was born. Do you __________?

		(Don’t read)
	Reasons	No (1)	Yes (2)	Refused (8)	Don’t know (9)
a.	Always use screens on open doors
b.	Always use screens on open windows
c.	Always keep unscreened doors and windows closed
d.	Always use fans or air conditioning
e.	Eliminate accumulated water from your house and yard on a weekly basis
f.	Sleep under a mosquito bed net
g.	Set up mosquito traps
h.	Spray inside your home for mosquitos
i.	Spray outside or around your home and yard for mosquitos
j.	Apply larvacides around the outside of your home

29. 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? Would you say that you use it every day, most days, some days, or never?

1 Every day

2 Most days

3 Some days

4 Never  Go to Question 31

(Don’t read) 8 Refused  Go to Question 31

9 Don’t know/don’t remember Go to Question 31

30. Since your new baby was born, when you use mosquito repellent on your exposed skin or clothing, how many times a day do you apply it? Would you say that you apply it more than once a day or once a day?

1 More than once a day

2 Once a day

(Don’t read) 8 Refused

9 Don’t know/don’t remember

INTERVIEWER: If the respondent used mosquito repellent on her skin or clothing every day when outside, go to Question 32.

31. I’m going to read a list of reasons that some people don’t wear mosquito repellent. For each one, please tell me if it is a reason for you? Would you say that you don’t wear mosquito repellent because_____________?

(PROBE: What are your reasons for not wearing mosquito repellent?)

		(Don’t read)
	Reasons	No (1)	Yes (2)	Refused (8)	Don’t know (9)
a.	You do not like the way it smells or it makes you nauseous
b.	You do not like the way it makes your skin feel
c.	You worry about the chemicals in the repellent harming you
d.	You forget to apply it
e.	You have an allergy or it makes your skin itch
f.	You don’t think you need it
g.	You are not worried about getting Zika virus
h.	You do not want to use it
i.	You are rarely outside
j.	Mosquito repellent is too expensive
k.	Is there some other reason?
l.	IF YES ASK: What is your other reason for not wearing mosquito repellent?_______________________________________________ _______________________________________________________ _______________________________________________________

32. How worried are you about getting infected with Zika virus now? Would you say that you are ____________?

1 Very worried

2 Somewhat worried

3 Not at all worried

(Don’t read) 8 Refused

9 Don’t know/don’t remember

The last questions are about testing for Zika virus.

33. I’m going to read a list of different time periods. For each one, please tell me if you got tested for Zika virus during that time. Were you tested for Zika virus _______________?

Time period	(Don’t read)
	No (1)	Yes (2)	Refused (8)	Don’t know (9)
Before your most recent pregnancy
During the first 3 months of your pregnancy or in the 1st trimester
During the middle 3 months of your pregnancy or in 2nd trimester
During the last 3 months of my pregnancy or in the 3rd trimester
After your most recent pregnancy

INTERVIEWER: If the mother was NOT tested for Zika virus at any time, go to the Question 36.

34. For each Zika test you received, please tell me how long you had to wait to receive the result. Was it received within one month, more than one month, or not received at all. When did you receive the results for the test that was done _____________?

(PROBE: Did you receive the results within in one month, more than one month, or you haven’t received your test result?)

Time period	(Don’t read)
	Within one month after being tested (1)	One month or more after being tested (2)	You haven’t received your test results (3)	Refused (8)	Don’t know (9)
Before your most recent pregnancy
During the first 3 months of your pregnancy or in the 1st trimester
During the middle 3 months of your pregnancy or in 2nd trimester
During the last 3 months of my pregnancy or in the 3rd trimester
After your most recent pregnancy

35. Where did you get tested for Zika virus? I’m going to read a list of locations for each time period when you got tested. For each one, please tell me if it was a place where you got tested. In the time ________, did you get tested for Zika at a _________?

(PROBE: Where did you get tested for Zika in the time ________________?)

	Time	Doctor’s office (1)	Health Dept. Clinic, Clínica 330 or IPA (2)	Hospital (3)	Laboratory, either private or commercial (4)	Other location (5)
a.	Before your most recent pregnancy
b.	During the first 3 months of your pregnancy or in the 1st trimester
c.	During the middle 3 months of your pregnancy or in 2nd trimester
d.	During the last 3 months of my pregnancy or in the 3rd trimester
e.	After your most recent pregnancy

INTERVIEWER: If the mother WAS tested for Zika virus at any time, go to Question 37.

36. I’m going to read a list of reasons why some people don’t get tested for Zika. For each one, please tell me if it was a reason that you did not get tested for Zika virus before, during, or after your most recent pregnancy? Was it because_____________?

(PROBE: Why didn’t you get tested for Zika? Was it because _____________)

		(Don’t read)
	Reasons	No (1)	Yes (2)	Refused (8)	Don’t know (9)
a.	You weren’t told to get tested or no one referred you for the test
b.	Testing locations were not easy to get to
c.	The test was too expensive
d.	You were afraid your health insurance was not going to pay for the test
e.	You were afraid of the result
f.	You didn’t think Zika was a problem
g.	You didn’t think you were at risk for Zika
h.	Was there some other reason why you did not have a Zika test?
i.	IF YES ASK: Why didn’t you gave a Zika test? ________________________________ _______________________________________________________ _______________________________________________________

37. During your most recent pregnancy, did a doctor, nurse, or other health care worker tell you or anyone else who lived with you that they were infected with Zika virus? For each person that I mention, please tell me if they were told that they had Zika.

(PROBE: Did a doctor, nurse, or other health care worker tell _________ that they had Zika virus during your pregnancy?)

Person:	(Don’t read)
	No (1)	Yes (2)	Refused (8)	Don’t know (9)
a. You
b. Your husband or any male partner
c. Another person who lives with you

38. In appreciation 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?

_____________________________________

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This finishes the interview. Is there anything you would like to say about your experiences around the time of your pregnancy or the health of mothers and babies in Puerto Rico?

INTERVIEWER: Record respondent’s verbatim comments below.

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Thanks for answering our questions. Your answers will help us work to keep Puerto Rico mothers and babies healthy. Goodbye.

INTERVIEWER:

Fill in today’s date: ______ / ______ / 20____ Time: ____________________ AM / PM

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