Att 8d_Detailed Summary of Changes

Summary of Changes to Questionnaire

Medical Monitoring Project

OMB # 0920-0740

Attachment 8d

Beginning in early 2016, CDC began an evaluation of the MMP questionnaire. The evaluation focused on examination of the relevance, coherence, and scientific contribution of interview questions. The result is a modified interview questionnaire (see Attachment 8c for the previously approved version of the questionnaire and Attachment 8a for the new version of the questionnaire. A redlined version was not feasible due to extensive reformatting of the questionnaire, which was necessary to reduce programming errors and automate the collection of meta-data).

Sections of the questionnaire were modified to improve the efficiency of administration and the quality of the data collected. For example, acquisition risk questions were removed because that data can be collected more effectively using the minimum dataset (MDS), and some injection drug use questions were removed because that data can be collected more comprehensively through the National HIV Behavioral Surveillance System (NHBS). In addition, questions about residence, reproductive health, gynecological care, and other topics were improved to ease participant comprehension. All new sections of the questionnaire were tested for comprehension through mock interviews. CDC staff conducted test interviews of the revised questionnaire using scenarios involving hypothetical respondents with different characteristics, and determined the average time to complete the interview was 45 minutes, which is the same administration time as the previously approved questionnaire. In addition, cognitive testing was performed to improve questions on HIV care experiences and barriers to care. The changes to the questionnaire are described in the following table.

Table 1. Proposed Modifications

Location in Documents	Modifications (with brief justification)	Question #(s)	Burden (Increase, Decrease, No change)	Total Number of Questions
Attachment 8c: p. 21 Attachment 8a: p. 5	Modified question in the “Age (YA)” section. Modified age variable to ask about age at sampling date rather than age at interview to better capture eligibility criteria. The new question will be used to verify if there is an error in data entry so persons younger than 18 are not interviewed.	8c: Removed: AGE_VER1 (YA.1.1) 8a: AGEVER_8 ( x)	No change	0
Attachment 8c: p.11-20	Removed 9 questions in the “Residence (YS)” section. The residency questions issues with recall, and comprehension. We simplified the topic, which resulted in the deletion of several extraneous questions.	8c: Removed: CURLVN5 (YS.1.0); NONMSTN5 (YS.1.2); LONGLVN5 (YS.1.3); LVPASN5 (YS.1.4); SAMPLVN5 (YS.2.0); NMSAMPN5 (YS.2.2); SPLV_N5 (YS.3.0); SPCTY_N5 (YS.3.1); NMMPSPN5 (YS.3.2)	Decrease	9
Attachment 8a: p. 6-11	Added 4 questions in the “Residence (YS)” section in order to assess eligibility, and to help project areas determine if a respondent should be included in their analytic sample if they want to limit their analyses to people who live in their project area.	8a: RESCURN8 (YS.1.0), RESAMPN8 (YS.2.0), RES2YN8 (YS.3.0) , CITY2N8 (YS.3.1)	Increase	4
Attachment 8c: p.11	Removed one question in “MMP participation (YM)”. This question was replaced with a skip pattern to improve efficiency and accuracy.	8c: Removed: CURCYN5 (YM.1.2)	Decreased	1
Attachment 8c: p. 22 Attachment 8a: p.31	The “Diagnosis date (YD)” topic is now under “HIV Care (K)” instead of “Eligibility Criteria (Y).”	8c: POS1S_9 (YD.1.0) 8a: POS1S_9 (YD.2.0)	No Change	0
Attachment 8c: p.26 Attachment 8a: p.16	Modified one question in the “Language ability (DL)” section. It was modified to better reflect the top 10 non-English languages spoken by MMP respondents.	8c: Modified: LANWL3N3 8a: LANWL3N8 (DL.2.1)	No change	0
Attachment 8a: p.18	Added three questions to the “Homeless (DH)” section that measure housing insecurity. Housing insecurity is a key demographic factor associated with care utilization and health outcomes.	8a: MOVESN8 (DH.2.0)- EVICTN8 (DH.4.0)	Increase	3
Attachment 8c: p.28 Attachment 8a: p.19	Modified one question in the “Incarceration (DJ)” topic. The question was modified so that persons who are currently incarcerated are asked about how many days they have currently spent in jail instead of being asked about the last time they were in jail.	8c: Modified: DYINCN5 (DJ.1.1) 8a: DYINCN5 (DJ.1.1)	No change	0
Attachment 8c: p. 31 Attachment 8a: p.22	Modified question in the “Income (FI)” section. The income brackets shown in the question are used to calculate Health and Human Services (HHS) poverty levels, which change every year. Thus, we needed to change the response categories. Categories in the lower range need to be small, so we can be nimble in keeping up with poverty levels over the duration of the 3-year cycle.	8c: Modified: INCOME_5 (FI.1.0) 8a: INCOME_8 (FI.1.0)	No change	0
Attachment 8c: p. 32-33	Removed all “Productivity Loss (FL)” questions. These questions were deleted because of poor comprehension and low-priority research questions.	8c: Removed: PRLS1_N5 (FL.1.0)-PRLS9_N5 (FL.4.0)	Decrease	7
Attachment 8c: p. 39-41	Removed “Affordable Care Act (FC)” topic. The questions belonging to this topic are now under the “Healthcare coverage” questions.	8c: Removed: ACAHNG_N5 (FC.1.0)- ACADEBT_N5 (FC.3.0)	Decrease	7
Attachment 8a: p.26-27	Added nine questions to the “Healthcare coverage (FH)” topic. These questions were previously under the “Affordable Care Act (FC)” topic.	8a: TYPE_N5 (FH.3.0)-BILLS_N5 (FH.3.6)	Increase	7
Attachment 8c: p.40 Attachment 8a: p.27	Modified the wording in questions originally found in the “Affordable Care Act (FC)” section. Specifically, we modified the wording of the question to ask about HIV care instead of outpatient HIV medical care. Participants did not understand the term “outpatient HIV medical care”. We used simpler language to improve comprehension throughout the questionnaire.	8c: Modified: Intro_ACAHCARE_N5 ACAHCARE_N5 (FC.1.3) ACAUSUAL_N5 (FC.1.4) 8a: Intro_HCARE_8, HCARE_8 (FH.3.3), USUAL_8 (FH.3.4)	No change	0
Attachment 8c: p. 42	Removed “HIV Testing Experiences (X)” module. We removed this module because of poor comprehension, issues with recall, and limited utility of the data collected.	8c: Removed: TESSETN5 (X.1.0) – MRTN5_OS	Decrease	3
Attachment 8c: p. 43-51	Removed “Never in care (K)” module. Removed module after discussions with subject matter experts. The module caused issues relating to question comprehension, and decision and judgement. We improved questions on barriers to care and placed them in “HIV care (K)” module. We will ask questions on barriers to accessing HIV care to everybody regardless of HIV care status.	8c: Removed: EVERCRN5 (K.1.0)- SEENMDN5 (K.5.0)	Decrease	32
Attachment 8c: p. 65	Removed “HIV care quality (VQ)” topic. This topic is now titled “Care Satisfaction (KS)”. In addition, we removed the phrase “outpatient HIV medical care”, which had poor respondent comprehension. This question is taken from the widely used Patient Satisfaction Questionnaire-8.	8c: Removed: GESTAN5 (VQ.1.0)	Decrease	1
Attachment 8c: p.22; p. 176 Attachment 8a: p.31	Added two questions to Diagnosis date (YD) section that were previously in the “Eligibility Criteria (Y)” module and “Acquisition Risk Behaviors (B)” module. We included these questions in the “HIV Care (K)” module to improve the flow of the questionnaire, and so that persons are not asked questions that are irrelevant to their lived experience.	8c: Removed: POS1S_9 (YD.1.0); IPERINN3 (BC.1.0) 8a: IPERINN3 (YD.1.0)-POS1S_9 (YD.2.0)	Increase	2
Attachment 8c: p. 43 Attachment 8a: p. 32	Added one question to the “Ever care (KE)” section in order to assess whether a respondent has ever received medical care for HIV. We modified the question to ask about HIV care instead of “outpatient HIV medical care”. Previously, this question was in the “Never in Care (K)” module.	8c: Modified: EVERCRN5 (K.1.0) 8a: EVERCR_8 (KE.1.0)	Increase	1
Attachment 8a: p.32-33	Added 8 questions to the “Referrals for linkage to care (KL)” topic. These questions were edited to improve comprehension and recall. In 2015-2017, the questions were asked of everybody in the “Linkage to Care (VL)” section. However, we are now limiting these questions to persons diagnosed less than 5 years from the interview date in order to improve recall, and to make these questions relevant to persons who may have experienced referrals to linkage to care. We cognitively tested these question as well.	8a: CARE1_8 (KL.1.0)- AREF3_8 (KL.8.0)	Increase	8
Attachment 8c: p. 52-55	Removed 11 questions in the “Linkage to care (VL)” section. Linkage to care questions were modified to include simpler language based on the results of cognitive testing. Questions about wanting linkage assistance were deleted because they do not answer our research question about whether services were offered. In addition, these questions were problematic for persons diagnosed many years ago when these services did not exist. The new questions in the “Referrals for linkage to care (KL)” section have been modified to address these issues.	8c: Removed: PREFN5 (VL.1.0)-CARE_9 (VL.6.0)	Decrease	11
Attachment 8c: p.55- 57 Attachment 8a: p. 33-34	Added 5 questions to the “Care Utilization (KU)” section. Previously, these questions were in the “Retention (VR)” section. These questions allow us to determine whether persons are retained in HIV care, and where to abstract medical records from.	8a: MSAPPT_8 (KU.1.0)- MLTFA2_8 (KU.4.1)	Increase	5
Attachment 8c: p.55-65	Removed 36 questions in the “Retention (VR)” section. Questions in this section were difficult to administer to participants and were inefficient. We determined the following questions to be low-priority: REEN5 (VR.10.0)-ENDGP_N5 (VR.10.2) and SEEOFTN5 (VR.6.0). Therefore, they were deleted. The recall period was modified to past 2 years to accommodate the 2-year surveillance period for the following questions: USOCN5 (VR.2.0), NYMLTFN5 (VR.3.0), and MLTFA1N5 (VR.3.2).	8c: Removed: LASCA_9- (VR.1.0) ENDGP_N5 (VR.10.2)	Decrease	36
Attachment 8a: p. 34	Added one question to the “Care Satisfaction (KS)” section. This question was previously under “HIV care quality (VQ)”. We modified the question to remove the phrase “outpatient HIV medical care”, which had poor respondent comprehension. This question is taken from the widely used Patient Satisfaction Questionnaire-8.	8a: GESAT_8 (KS.1.0)	Increase	1
Attachment 8a: p.35-37	Added 14 questions to the “Patient-provider relationship (KB)” section. This section includes the Health Care Relationship (HCR) Trust Scale. The scale has reliability and validity as a measure of patient trust among persons living with HIV (PLWH). A patients’ trust in their provider has been related to adherence, continuity of care, and return for follow up.	8a: HCPROVN8 (KB.1.0)- TRUS13N8 (KB.14.0)	Increase	14
Attachment 8a: p. 37-38	Added 6 questions to the “Barriers and facilitators to care (KP)” section. This question captures what barriers PLWH encounter when accessing HIV care. These questions were cognitively tested for comprehension, recall, social desirability, and response.	8a: BARRI1N8 (KP.1.0)- FACCI1N8 (KP.6.0)	Increase	6
Attachment 8c: p.66-74	Modified “HIV treatment and adherence” module. Thirty-nine questions that were previously under the “HIV treatment and adherence (T)” module are now placed in different topics. In addition, we removed 7 questions on prescription drug use from the “HIV treatment and adherence” module and placed them in the “General Medical Care (J)” module. These questions will now be asked of everybody, regardless of whether or not they are taking HIV medications.	8c: Removed: EART_N5 (T.1.0)-PRMD6_N5 (T.11.5)	Decrease	39
Attachment 8a: p. 39-40	Created the “Ever ART (TE)” topic that was previously under the “HIV treatment and adherence” module. This topic has 8 questions. No questions are new or modified.	8a: EART_N5 (TE.1.0)-FART_N5 (TE.2.0)	Increase	8
Attachment 8a: p. 41-42 Attachment 8c: p.68	Created the “Current ART (TC)” topic that was previously under the “HIV treatment and adherence” module. This topic has 8 questions. No questions are new or modified. Modified language in one introduction statement.	8c: Modified: Intro_CART1_N5 8a: CART1_N5 (TC.1.0) – CART6_N5 (TC.2.6); Intro_8_CART1_N5	Increase	8
Attachment 8a: p.42-45	Created the “Adherence (TA)” topic that was previously under the “HIV treatment and adherence” module.	8a: ADH1_N5 (TA.1.0)- PROB_N5 (TA.7.0)	Increase	15
Attachment 8a: p. 43- 44 Attachment 8c: p.70	Modified one question in the “Adherence (TA)” topic because it was not performing well in the field. The question was too lengthy and caused retention and comprehension problems. This question was split into two questions in order to improve comprehension.	8c: Removed: MIS1_N5 (T.7.0) 8a: MIS1N5_8 (TA.5.0); MIS10_N8 (TA.5.9)	Increase	1
Attachment 8a: p. 43	Added a screener question to the “Adherence (TA)” topic to ensure that people who report never having missed a dose of HIV medications do not get questions about reasons for missing a dose of their medication.	8a: MISEVRN8 (TA.4.0)	Increase	1
Attachment 8a: p. 45	Added the “HIV treatment as prevention (TB)” topic, which assesses awareness of the treatment as prevention (TasP) strategy over time. These data can be used to compare awareness of TasP to health and behaviors.	8a: TASP1N8 (TB.1.0)	Increase	1
Attachment 8c: p.75	Removed “Other care (JO)” topic. Removed question on participation in HIV clinical trials because of low comprehension and low-priority research question.	8c: Removed: CLTREC_9 (JO.1.0)	Decrease	1
Attachment 8c: p.76 Attachment 8a: p. 30	Relocated “Health literacy (HL)” module. It is no longer its own module. It is now part of the “General Medical Care (J)” module.	8c: HLMF_12 (HL.1.0) 8a: HLMF_12 (JL.1.0)	No change	0
Attachment 8a: p. 28	Added a question on health and well-being to the “Health and well-being (JW)” topic. The National Health Interview Survey (NHIS) uses this question to assess self-rated health, which is a predictor of morbidity and mortality. Research and large-scale studies use self-rated health measures because they have shown to be valid health status indicators.	8a: GENHLTN8 (JW.1.0)	Increase	1
Attachment 8a: p. 29-30	Created the “Prescription Medicines (JP)” module, which was previously under “HIV treatment and adherence (T)”. Added 7 questions on prescriptions, which we will ask of everybody, regardless of whether or not they are also taking HIV medications. We will use these data to compare to NHIS 2012 general population survey.	8a: P12_N5 (JP.1.0)-PRMD6_N5 (JP.2.5)	Increase	7
Attachment 8c: p. 156	Removed question in “Prevention activities (PA)” section because of low-priority research question and data quality concerns.	8c: Removed: HIVINFN3 (PA.2.0)	Decrease	1
Attachment 8c: p. 156 Attachment 8a: p. 117-119	A “Prevention Messages (PM)” and “Risk reduction (PR)” topic were added to the “Prevention activities (PA)” module. Previously, the “Prevention activities” module had no topics. The “Risk reduction (PR)” topic contains questions from 2015-2017.	8c: COND12_9 (PA.1.0) - GROU1_12 (PA.3.3) 8a: INFTX1N8 (PM.1.0)- GROU1_12 (PA.3.0)	No change	0
Attachment 8a: p. 117-118	Created new topic titled “Prevention Messages (PM)”. These questions will be used to determine where persons living with HIV (PLWH) search for HIV care and treatment information in order to target prevention messaging. These questions will also be used to identify whether there is variation in trusted sources by different subgroups, and to measure the efficacy of the “HIV Treatment Works” campaign.	8a: INFTX1N8 (PM.1.0) - HTWCMPN8 (PM.3.0)	Increase	9
Attachment 8c: p. 161 Attachment 8a: p. 127	Removed two questions for binge drinking and replaced with one question in the “Alcohol Use (UA)” topic. Previously, there were two questions for males and females. In order to reduce the number of questions in the survey, we created a token question which will automatically populate depending on the person’s gender.	8c: Removed: DRINK5_9 (UA.5.0)- DRINK4_9 (UA.6.0) 8a: BINGE_8 (UA.4.0)	Decrease	1
Attachment 8c: p. 160	Removed question about alcohol use “before or during sex” in “Alcohol Use (UA)” topic. This question does not adequately capture if a respondent was impaired before or during sex.	8c: Removed: ALCOHOL1 (UA.2.0)	Decrease	1
Attachment 8c: p. 162-163 Attachment 8a: p.128	Modified one question in the “Cigarette and tobacco use (US)” topic, and removed one lengthy introduction statement. Modified question so that it would read “healthcare worker” instead of “healthcare provider”. This ensures consistency in wording throughout the questionnaire. Removed Intro_CIGARN5, which is an introduction statement. This statement was too lengthy and cumbersome for interviewers and respondents, and did not affect the comprehension of the question that followed.	8c: Removed: Intro_CIGARN5; Modified: CIG_DQN5 (US.4.0) 8a: CIG_DQ_8 (US.4.0)	No change	0
Attachment 8c: p. 163-168	Removed questions in the “Non-injection drug use (UN)” topic. Removed questions that ask about substance use “before or during sex” because they do not adequately capture if a respondent was impaired before or during sex. Removed question on the use of erectile dysfunction drugs. This question did not belong in a module about drug use, and had low research priority compared to other question.	8c: Removed: MARI_SN5 (UN.1.2) CRACKSN5 (UN.2.1) COC_SN5 (UN.3.1) METH_SN5 (UN.4.1) AMPH_SN5 (UN.5.1) CLUB_SN5 (UN.6.1) POPP_SN5 (UN.7.1) PAIN_SN5 (UN.8.1) TRAQ_SN5 (UN.9.1) EDMD_SN5 (UN.10.0)	Decrease	10
Attachment 8a: p. 130	Added question on heroin use to “Non-injection drug use (UN)” topic. We asked this question in 2009-2014, but retired it in 2015-2017. We included it in 2018-2020 due to an increased interest in opioid addiction.	8a: Heroin_9 (UN.7.0)	Increase	1
Attachment 8c: p. 169- 175	Removed detailed questions on injection drug use in the “Injection drug use (UI)” topic. Other surveillance systems such as the National HIV Behavioral Surveillance System (NHBS) capture this information better than MMP. In addition, very few respondents get these questions.	8c: Removed: INJSEXN5 (UI.8.0), SHRNUMN5 (UI.9.1), SHR1SXN5 (UI.9.2), SHRSEXN5 (UI.9.3), SHR1PON5 (UI.9.4), SHRPOSN5 (UI.9.5), USENDBN5 (UI.11.1)- DRUGTXN5 (UI.12.0)	Decrease	12
Attachment 8c: p. 176-178	Removed 6 questions in the “Core acquisition risk (BC)” topic. The minimum dataset in the National HIV Surveillance System (NHSS) can be used to determine how HIV was acquired. Question IPERINN3 (YD.1.0), which asks whether the participant was born with HIV, is now in the “Diagnosis date (YD)” topic.	8c: Removed: IPERINN3 (BC.1.0)-ISEXFEN3 (BC.5.0)	Decrease	6
Attachment 8c: p. 178-179	Removed the “Female heterosexual series (BF)” questions. These questions were deleted because the minimum dataset in the National HIV Surveillance System (NHSS) can be used to determine how HIV was acquired.	8c: Removed: IFSXHIN3 (BF.1.0)- IFSXBIN3 (BF.4.0)	Decrease	4
Attachment 8c: p. 179-180	Removed the “male heterosexual series (BM)” questions. These questions were deleted because the minimum dataset in the National HIV Surveillance System (NHSS) can be used to determine how HIV was acquired.	8c: Removed: IMSXHIN3 (BM.1.0) - IMSXHEN5 (BM.3.0)	Decrease	3
Attachment 8c: p. 180	Removed “Additional acquisition risk questions for persons born prior to March 1985 (BA)” questions. These questions were deleted because the minimum dataset in the National HIV Surveillance System (NHSS) can be used to determine how HIV was acquired.	8c: Removed: ITRANN3 (BA.1.0)-ITRP85N5 (BA.2.1)	Decrease	4
Attachment 8c: p. 181-199	Removed questions in the “Services and assistance programs (ND)” topic. Removed questions on certain service and assistance programs because of low-priority research questions and low endorsement in previous cycles. These include questions about SSDI, SSI, interpreter services and lawyer/legal services. The removal of these questions also entails the removal of subsequent questions on the reasons for not getting the service despite needing it.	8c: Removed: SSIA_N5 (ND.12.0)- SSDID_N5 (ND.13.4); GET_INTS (ND.17.0)- LAWYB_N5 (ND.18.5)	Decrease	22
Attachment 8c: p. 199 Attachment 8a: p. 166-167	Modified the “Other disability (NS)” topic. We added two questions that ask about receipt of SSI and SSDI in the past 12 months. If respondents say they received these services, they are asked when they first got these services. We also included definitions for SSI and SSDI in order to clarify the differences between both programs. Including a brief definition may improve comprehension and will allow interviewers to provide definitions in a standardized manner.	8c: Modified: DISSIN5 (NS.1.0) – DISSDIN5 (NS.2.0) 8a: SSIA_N8 (NS.1.0)- DSSDIN8 (NS.2.1)	Increase	2
Attachment 8a: p.138	Added three questions to the “Stigma (RS)” topic. In order to monitor stigma trends over time, we need to measure experiences of stigma in the past 12 months. The three questions with a 12-month reference period are about specific events that could have occurred now or in the past.	8a: STGA12N8 (RS.11.0)- STFC12N8 (RS.13.0)	Increase	3
Attachment 8c: p. 203-205 Attachment 8a: p. 139-141	Added and removed questions to the “Discrimination (RD)” topic. Added 13 questions and removed 8 questions on discrimination. In 2015-2017, 3 questions composed the discrimination scale (RD.1.0-RD.3.0). In 2018, we plan to change this scale to capture more subtle, everyday forms of healthcare discrimination. Therefore, we added 7 questions (RD.1.0-RD.7.0). We slightly altered the wording of five questions (RD.4.0-RD.8.0) on whether discrimination occurred because of sociodemographic factors to read more efficiently. In addition, we added one question (DISINCN8, RD.12.0) to assess whether the discrimination occurred because of income or social class.	8c: Removed: STIGMA2A (RD.1.0)- STIGMA3E (RD.8.0) 8a: DISC1N8 (RD.1.0)-DISDRG_8 (RD.13.0)	Increase	5
Attachment 8c: p.206, 208 Attachment 8a: p. 142-143	Added three questions to the “Gynecological Care (GH)” topic, and modified one. Questions about post-menopause, tubal ligation, and hysterectomies were previously placed under “Contraception (GC)”, but were moved to “Gynecological care (GH)” because women who experience this should be skipped out of the contraceptive use questions, as these questions are not relevant to their experiences. In addition, we will ask the tubal ligation and hysterectomy questions separately in order to improve comprehension. Previously, both were asked as one question (8c: GC.1.15, pg.208). Last, one question was modified in order to change the reference period to the past 3 years to reflect clinical recommendations according to the “Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents”.	8c: Modified: PAP_EX_9 (GH.1.0) 8a: Modified: PAP_EX_8 (GH.1.0) Added: POSTMEN8 (GH.3.0)-HYSTERN8 (GH.5.0)	Increase	3
Attachment 8c: p. 206-209 Attachment 8a: p. 143-144	Modified three questions in the “Contraception (GC)” topic in order to provide clearer definitions of the following forms of contraception: intrauterine devices, hormonal implants, and hormonal injections.	8c: Modified: BIRCOEN3 (GC.1.5); BIRCOFN3 (GC.1.6); BIRCOJN3 (GC.1.10) 8a: BIRCOE_8 (GC.1.5); BIRCOF_8 (GC.1.6); BIRCOJ_8 (GC.1.10)	No change	0
Attachment 8c: p. 208	Removed two questions from the “Contraception (GC)” topic. These two questions were removed from this topic and placed in the “Gynecological Care (GH)” topic. They were modified to ease comprehension.	8c: Removed: BIRCONN3 (GC.1.14); BIRCOON3 (GC.1.15)	Decrease	2
Attachment 8a: p. 145	Added one question to “Reproductive History (GR)”. This question measures pregnancy intentions. We added this question to understand factors associated with women’s intentions to become pregnant. Data on women’s intentions to become pregnant can be used to help women living with HIV prevent unwanted pregnancies, or conceive and give birth safely.	8a: INTENTN8 (GR.1.0)	Increase	1
Attachment 8c: p. 129 Attachment 8a: p.16	The “Foreign born (LF)” topic has been renamed “U.S. born (DF)” and is no longer under the “Foreign-born and immigration (L)” module. It is now part of the “Basic Demographics (D)” module.	8c: CO_BORN (LF.1.0)- US_YRS (F.1.1) 8a: CO_BORN (DF.1.0)- US_YRS (DF.1.2)	No change	0
Attachment 8c: p.220	Removed “Immigration status (LI)” topic. Removed two questions on citizenship (L1.1.0) and residency status (LI.1.1). Removed the question because of issues with sensitivity and loss of rapport between interviewer and respondent.	8c: Removed: CIT_N5 (LI.1.0)- GC_N5 (LI.1.1)	Decrease	2
Attachment 8c: p. 221-223	Removed the “Health Conditions and Preventive Therapy (C)” module. This module included one question about HPV, which we removed because of high refusal rates, poor comprehension and recall, and possible issues with data quality. Removed four questions on tuberculosis (CT.1.0-CT.1.3) because of possible issues with data quality, low utility of the data, and low-priority research questions. In addition, influenza questions now belong to the “General Medical care (J)” module (JF.1.0-JF.1.1)	8c: Removed: HPV_EVR (CP.1.0)- ACTVTBN3 (CT.1.3)	Decrease	5
Attachment 8c: p. 222-223 Attachment 8a: 28-29	The “Influenza (CF)” topic now belongs to the “General Medical Care (J)” module. Modified two questions with simpler and more consistent language. We are now asking about the “flu shot” versus “seasonal flu vaccine” (CF.1.1.) and “vaccine or shot to protect you from the seasonal flu” (CF.1.0). Modified response categories for CF.1.1 to include “hospital or emergency room” and changed “employer” to “workplace”. Removed one question that asked respondents to specify where they got their most recent flu shot if they could not pick an answer. We removed this question because of the low utility of those data.	8c: Modified: VACFL_10 (CF.1.0); LOCVA_10 (CF.1.1); Removed: LOC_10OS (p. 223) 8a: VACFL_8 (JF.1.0) LOCVA_8 (JF.1.1)	Decrease	1
Attachment 8a: p. 169	Added one questions to the “Referrals and Follow-up (EO)” topic. This question assesses whether smoking cessation services were provided to current smokers (EO.3.0). This is the only “Referrals and Follow-up” question asked of participants. Interviewers are supposed to provide services to never-in-care and out-of-care respondents.	8a: SMOKCEN8 (EO.3.0)	Increase	1

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