Change Request Justification

Change Request

December 20, 2017

“Zika Postpartum Emergency Response Survey (ZPER), Puerto Rico, 2017”

OMB no. 0920-1199, exp. date 9/30/2018

Background and Justification

CDC is approved to collect information to assess knowledge, awareness, and use of prevention measures to help pregnant women in Puerto Rico avoid Zika, and to assess postpartum health and infant care in the aftermath of the 2016 Zika outbreak using the PRAMS Zika Postpartum Emergency Response Survey (ZPER). Since approval of ZPER (OMB no. 0920-1199), the severe and long-lasting impacts of Hurricanes Irma (September 6, 2017) and Maria (September 20, 2017) have become apparent. This Change Request is to modify a subset of existing questions to assess the impact and available resources for pregnant and postpartum women and infants in relation to these recent hurricanes in addition to Zika.

CDC obtained approval for information collection in September 2017 and is requesting five changes, as outlined below. These changes will only affect the second cohort of the ZPER Telephone Follow-up Survey. Burden hours reflect the first cohort of women who completed the telephone follow-up survey (Attachment 9a,b – currently approved version) and the second cohort will be asked to complete this revised survey (Attachment 9a,b – proposed revised version) .

Change #1.

We propose adding four response options to two approved question that address barriers to receiving health care services. One question pertains to barriers for women receiving postpartum care, and the other pertains to infants receiving health care visits. These additions are being proposed to assess barriers to care in Puerto Rico following Hurricanes Irma and Maria that were not present when the original survey was developed. The added response options are the same for both questions and are listed below, as applied to approved questions #2 and #12. We would like to propose that a skip instruction to the interviewers following the question about barriers to infant care to route women for whom subsequent questions about infant health care are not relevant past the questions. Proposed additions are in red. All other aspects of the questions remain unchanged.

The new response options are in red:

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

Change #2.

We propose adding one response option to approved question #25 that addresses barriers to use of contraception in the postpartum period. This addition is being proposed to assess potential barriers to obtaining contraception in Puerto Rico following Hurricanes Irma and Maria that were not present when the original survey was developed. All other aspects of the questions remain unchanged.

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 have or had problems getting contraception due to the hurricane (doctor office closed, pharmacies closed, method not available, 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? ___________________________________________________________________ ___________________________________________________________________

Change #3.

We propose adding four questions pertaining to maternal mental health and receipt of mental health services. Puerto Rico has suffered two population-wide emergencies in the last year; the Zika outbreak and the recent hurricanes. These experiences have caused considerable disruption and strain on living conditions and access to health care. The proposed additions would provide information on the mental health status of new mothers in the face of these challenges.

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 9

Yes

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

No

Yes

Change #4.

We propose adding one question following approved question #10. This question would allow us to assess the challenges of caring for infants in the early postpartum period that may be unusual in the aftermath of the Zika and hurricane emergencies over the past year. The proposed additions would provide information to understand infant health outcomes in the context of the Zika outbreak by including information on barriers to caring for babies that were not present prior to the hurricanes.

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 Hurricanes Irma and Maria? 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

Change #5.

We propose deleting 13 questions (#5, 13, 18, 28 – 37 on the approved survey) . Sufficient information has been collected through the first round of data collection on the topics addressed in these questions. In addition, we propose to eliminate a description of what a health care visit is from question #11, in that this did not provide additional clarification but added time.

Timeline and Impact on Burden

CDC plans to begin administering the revised instruments in February 2018.  The estimated average annualized burden per response will decrease for two reasons: 1) the number of women and fathers planned to be recruited for Cohort 2 of the hospital based and telephone follow-up survey will be reduced because of the disruption of infrastructure, and 2) the proposed revised telephone survey has been reduced in length from 38 to 30 questions, and the estimated time-burden has been reduced from 15 to 12 minutes.

Estimated Annualized Burden Hours Before Proposed Changes

Type of Respondent	Form Name	No. of Respondents	No. of Responses per Respondent	Average Burden per Response (in hours)	Total Burden Hours
Women with recent births –Cohort 2	Hospital-based survey for mothers (Attachment 7a,b)	2,990	1	25/60	1,246
Fathers/partners with recently born infants- Cohort 2	Hospital-based survey for fathers/partners (Attachment 8a,b)	1,790	1	15/60	448
Women with live births 2-10 months prior-Cohort 1 and 2	Telephone follow-up survey (Attachment 9a,b)	3,070	1	15/60	768
Total					2,462

Estimated Annualized Burden Hours After Proposed Changes

Type of Respondent	Form Name	No. of Respondents	No. of Responses per Respondent	Average Burden per Response (in hours)	Total Burden Hours
Women with recent births –Cohort 2	Hospital-based survey for mothers (Attachment 7a,b)	1,600	1	25/60	667
Fathers/partners with recently born infants- Cohort 2	Hospital-based survey for fathers/partners (Attachment 8a,b)	1,280	1	15/60	320
Women with live births 2-10 months prior Cohort 1	Telephone follow-up survey (Attachment 9a,b) – currently approved version	1,550	1	15/60	388
Women with live births 2-10 months prior Cohort 2	Telephone follow-up survey (Attachment 9a,b) – proposed revised version	1,520	1	12/60	304
Total					1,679

6