Form 0920-1199 ZPER Telephone Follow-Up Questionnaire - English

ZPER 2.0 Telephone Follow-up Questionnaire – English phone version

Form Approved

OMB No. 0920-1199

Exp. Date 08/31/2017

Public reporting burden of this collection of information is estimated to average 12 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.	Road conditions made it unsafe to travel after Hurricane’s Irma and Maria
h.	You weren’t able to get enough gasoline or diesel to drive after Hurricane’s Irma and Maria
i.	You were afraid to leave where you were staying after Hurricane’s Irma and Maria
j	Services were not available due to damage to the clinics form the hurricanes
k.	Did you have some other reason?
l.	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

4a. Since your new baby was born, how often have you felt down, depressed, or hopeless? Would you say that it’s been always, often, sometimes, rarely, or never?

(Don’t read) 1 Always

2 Often

3 Sometimes

4 Rarely

5 Never

8 Refused

9. Don’t know/don’t remember

4b. Since your new baby was born, how often have you had little interest or little pleasure in doing things you usually enjoyed? Would you say that it’s been always, often, sometimes, rarely, or never?

(Don’t read) 1 Always

2 Often

3 Sometimes

4 Rarely

5 Never

8 Refused

9 Don’t know/don’t remember

4c. Since your new baby was born, have you felt that you have needed mental health services such as counseling, medications, or support groups to help with feelings of anxiety, depression, grief, or other issues?

No  Go to Question 5

Yes

4d. Were you able to get the mental health services that you needed?

No

Yes

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

6. 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

6. 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

6. 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

6. 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

10a. In the month after your baby was born, did you experienced any of the following problems caring for your baby due to the situation caused by the hurricanes? I’m going to read a list of problems. For each one, please tell me if you experienced it. Did you __________?

		(Don’t read)
	Problem	No (1)	Yes (2)	Refused (8)	Don’t know (9)
a.	Have problems getting medical attention your baby needed
b.	Have problems getting medical attention for yourself
c.	Have problems feeding your baby
d.	Have problems getting enough money to take care of your baby
e.	Have problems getting clean water to bathe your baby
f.	Have problems providing a safe place for your baby to sleep
g.	Have problems protecting your baby from mosquito-borne infections
i.	Have problems paying your bills
j.	Have problems getting money out of the bank

6. 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?

(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

6. 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.	Road conditions made it unsafe to travel after Hurricane’s Irma and Maria
h.	You weren’t able to get enough gasoline or diesel to drive after Hurricane’s Irma and Maria
i.	You were afraid to leave where you were staying after Hurricane’s Irma and Maria
j	Services were not available due to damage to the clinics form the hurricanes
k.	Did anything else keep your baby from having a health care visit?
l.	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.

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

14. 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

14. 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

14. 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

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.

19. 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

19. 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

19. 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

19. 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.

23aHow 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

19. 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

19. 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
You had problems getting contraception due to the hurricane (doctor office closed, pharmacies closed, etc.)
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.

19. 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? _________________________________________________________________________ _________________________________________________________________________________________________________________________________________________

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

Month Day Year

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