Form 0920-1156 Health Center Provider Survey

Form Approved

OMB No. 0920-1156

Exp. Date xx/xx/xx xx/xx/xxxx xx/xx/xxxx

Health Center Provider Survey

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Thank you for agreeing to complete this survey. The purpose of the survey is to assess your attitudes and practices related to adolescent sexual and reproductive health. Please answer each of the following questions as they relate to your experiences providing family planning services to your adolescent patients. Please answer questions thinking only about services you have provided at your current health center.

Your responses will be kept private and your completed assessment will be stored on a secure, password protected server. Your responses will be combined with those from others at your health center in order to tailor training and technical assistance. Your individual responses will not be shared. Your participation in this survey is voluntary and you can discontinue participation at any time.

PROVIDER AND PATIENT CHARACTERISTICS

1. On average, approximately how many unduplicated female patients ages 15-19 do you see per week? ______(provide a whole number)

2. Approximately what percent of your female patients ages 15-19 do you provide sexual and reproductive health services?

0-24%

25-49%

50-74%

75% or more

TRAINING

3. Have you been formally trained in the insertion and removal of the following contraceptive methods?

	Yes	No
Copper Intrauterine Device (Cu-IUD or ParaGard®)?
Levonorgestrel-releasing Intrauterine Device (LNG-IUD LILETTA™, Skyla® or Mirena®)?
Contraceptive implant (Implanon®)?

ATTITUDES AND PRACTICES

4. How comfortable are you recommending IUDs for the following groups of adolescents (ages 15 to 19 years old)?

	Not at all comfortable	Slightly comfortable	Somewhat comfortable	Moderately comfortable	Very comfortable
Nulliparous adolescents?
Postpartum adolescents (10 minutes after delivery of placenta to less than 4 weeks postpartum)?
Obese adolescents (BMI ≥30 kg/m2)?

5. In the past year, have you referred, prescribed or provided IUDs to nulliparous adolescents?

• Yes

• No

If no, please indicate why (Select all that apply):

• My practice/health center does not provide IUDs.

• I do not have nulliparous adolescents as patients.

• I am concerned about recommending IUDs for adolescents.

• I am concerned about the effects on future fertility.

• I am concerned about difficult insertion.

• I am not trained in IUD insertion.

• My nulliparous adolescent patients generally prefer a different method.

• Adolescents are more likely to have it removed within a year of insertion, compared to adults

• My practice/health center protocol does not allow it.

• There are financial-related issues with billing, coding, and reimbursement processes that make the process very difficult.

• Providing adolescents with IUDs makes them less likely to use a condom

• I do not feel comfortable inserting IUDs.

• I do not generally provide IUDs to adolescents for other reasons (please specify): __________________________________________________

6. In the past year, have you referred, prescribed or provided hormonal implants to nulliparous adolescents?

• Yes

• No

If no, please indicate why (select all that apply):

• My practice does not provide implants.

• I rarely have nulliparous adolescents as patients.

• I am concerned about recommending implants for adolescents.

• I am concerned about the effects on future fertility.

• I am concerned about difficult insertion.

• I am not trained in implant insertion.

• My nulliparous adolescent patients generally prefer a different method.

• Adolescents are more likely to have it removed within a year of insertion, compared to adults

• Providing adolescents with hormonal implants makes them less likely to use a condom

• My practice/health center protocol does not allow it.

• There are financial-related issues with billing, coding, and reimbursement processes that make the process very difficult.

• I do not feel comfortable inserting implants.

• I do not generally provide implants to adolescents for other reasons (please specify): __________________________________________________

7. Before providing the following contraceptive methods, please indicate if you perform any of the following exams and tests for an otherwise healthy female adolescent.

Contraceptive Method	Blood pressure	Clinical breast exam	Bimanual exam and cervical inspection	Cervical cytology	Chlamydia/ gonorrhea screening	Do not provide this method
COCs/patch/ring	YES NO	YES NO	YES NO	YES NO	YES NO
Progestin-only pills (POPs)	YES NO	YES NO	YES NO	YES NO	YES NO
DMPA (Depo-Provera®)	YES NO	YES NO	YES NO	YES NO	YES NO
Contraceptive implant (Implanon®)	YES NO	YES NO	YES NO	YES NO	YES NO
Copper Intrauterine Device (Cu-IUD or ParaGard®)	YES NO	YES NO	YES NO	YES NO	YES NO
Levonorgestrel-releasing Intrauterine Device (LNG-IUD LILETTA™, Skyla® or Mirena®)	YES NO	YES NO	YES NO	YES NO	YES NO

8. In the past year, how frequently have you provided the following services for adolescent females?

	Never	Rarely	Sometimes	Often	Always
Provided or prescribed the pill, patch, ring or Depo Provera on the day of her visit regardless of the timing of her menses (Quick Start)
Provided a hormonal implant on the day of her visit regardless of the timing of her menses (Quick Start) if you were reasonably certain she was not pregnant
Provided an IUD on the day of her visit regardless of the timing of her menses (Quick Start) if you were reasonably certain she was not pregnant
Provided or prescribed a contraceptive method at the same time you provided EC
Provided contraceptive services to an adolescent that came in for a pregnancy test that was negative
Provided a Cu-IUD as EC
Provided another method of birth control if selected method not available on day of visit
Dispensed a year’s supply of pills at one visit for adolescent females
Addressed contraceptive needs on the day of service regardless of chief complaint rather than scheduling a follow-up visit

9. In the past month, when counseling your typical female patient ages 15 to 19 years old on family planning, how frequently did you (or your clinical team) do the following?

	Never	Rarely	Sometimes	Often	Always
Assessed the patient’s reproductive life plan (i.e., asked about their intentions regarding the number and timing of pregnancies in the context of their personal values and life goals)	☐	☐	☐	☐	☐
Worked with the client interactively to select the most effective method that meets the client’s needs and preferences	☐	☐	☐	☐	☐
Presented information regarding potential contraceptive methods with the most effective methods presented first (tiered approach)	☐	☐	☐	☐	☐
Helped the patient think about potential barriers to using their selected method correctly and develop a plan to deal with these barriers	☐	☐	☐	☐	☐
Used a method-specific informed consent form	☐	☐	☐	☐	☐
Informed adolescents that long-acting reversible contraceptives are safe and effective options	☐	☐	☐	☐	☐
Actively encouraged communication between adolescents and parents/guardians about sex and reproductive health	☐	☐	☐	☐	☐
Encouraged male/partner involvement in contraceptive and reproductive health services, if appropriate	☐	☐	☐	☐	☐

SERVICES TO ADOLESCENTS NOT INITIALLY SEEKING SEXUAL OR REPRODUCTIVE HEALTH CARE

The following items are about services provided to your adolescent patients who were seeking health care for a purpose other than sexual or reproductive health care (e.g., sick visit).

☐ Check here if you only see family planning clients. You have completed the survey. Thank you.

10. In the past month, when your female adolescent patients (ages 15 to 19 years old) were seeking health care for a purpose other than sexual or reproductive health care (e.g., sick visit), how frequently did you or your clinical team do the following?

	Never	Rarely	Sometimes	Often	Always
Provide time alone	☐	☐	☐	☐	☐
Screen to determine if in need of contraceptive services (i.e., sexually active, not desiring pregnancy)	☐	☐	☐	☐	☐

11. In the past month, when your male adolescent patients (ages 15 to 19 years old) were seeking health care for a purpose other than sexual or reproductive health care (e.g., sick visit), how frequently did you or your clinical team do the following?

	Never	Rarely	Sometimes	Often	Always
Provide time alone	☐	☐	☐	☐	☐
Screen to determine if in need of counseling around preventing pregnancy	☐	☐	☐	☐	☐

Thank you.