Form 0920-22CC BAA HCP Pre Campaign Screener and Survey

Attachment E: BAA HCP Pre-Campaign Screener and Survey

Form Approved

OMB No. 0920-XXX

Expiration Date XX/XX/XXXX

baa hcp pre-campaign SCREENER [ALL]

HCP Audiences

• Hospitalist

• Dentist

• Community pharmacists 

• Physicians and advanced practice providers in nursing homes

• Nurses in nursing homes 

 

General Instructions for Programmer

1. Hide all subheadings of sections and questions from respondents.

2. Hide all programmer’s instructions from respondents.

3. For questions with the “Select all that apply” option, do not allow respondents to select any other option if they select “Prefer not to say,” “Do not know/cannot recall,” “Not sure,” “Nothing,” or “None of the above.”

4. Terminate also means ineligible.

5. Terminate all eligible respondents immediately.

6. Present the “Ineligibility Message” whenever a response terminates the survey.

Thank you for participating in this survey. The results will help the Centers for Disease Control and Prevention (CDC) refine its ongoing campaign to improve antibiotic use.

Programmer: Include one question per page. Screener should terminate as soon as the respondent selects an option that deems him/her ineligible.

1. May we ask you some questions to see if you are eligible to take this survey?

• Yes

• No [INELIGIBLE/TERMINATE]

Programmer: If “No” to Q1, TERMINATE. If “Yes,” proceed to Q2. 

2. Are you a healthcare professional (e.g., physician, physician assistant, nurse practitioner, nurse, pharmacist, or dentist)?

• Yes

• No [INELIGIBLE/TERMINATE]

3. In what ZIP Code(s) and State do you work? (Please list the ZIP Codes of all the locations you work) ______

Programmer: Targeted states include Iowa (IA), Nebraska (NE), Tennessee (TN), and Alabama (AL). 

Programmer: Approved ZIP Codes include XXXXX, XXXXX, XXXXX, etc. If not within one of the target states and approved ZIP Codes, TERMINATE, otherwise, proceed to Q3.

4. Specifically, what type of healthcare professional are you?

• Physician (MD or DO)

• Physician Assistant (PA)

• Dentist (DDS or DMD)

• Pharmacist (PharmD or RPh)

• Nurse Practitioner (NP)

• Registered Nurse (RN, including ADNs and BSNs)

• None of the above [INELIGIBLE/TERMINATE]

5. What type of setting do you spend the most time providing patient care?

• Hospital

• Nursing home/Long-Term Care

• Retail pharmacy

• Dental office

• Urgent care facility [INELIGIBLE/TERMINATE]

• Primary care practice/facility [INELIGIBLE/TERMINATE]

• Outpatient [INELIGIBLE/TERMINATE]

• None of the above [INELIGIBLE/TERMINATE]

6. On average, how many hours a week do you provide patient care?

• 0-10 hours [INELIGIBLE/TERMINATE]

• 11-20 hours [INELIGIBLE/TERMINATE]

• 21-30 hours [INELIGIBLE/TERMINATE]

• 31 or more hours

7. On average, how often do you prescribe antibiotics/provide antibiotics to patients?

• Multiple times every week

• Once a week

• 1-3 times a month [INELIGIBLE/TERMINATE]

• Never [INELIGIBLE/TERMINATE]

Categorize Respondents

Programmer:

Categorize respondents as “Hospitalists” if their response(s) to

• Q4 = Physician (MD or DO), Physician Assistant (PA), Nurse Practitioner (NP)

• Q5 = Hospital

• Q6 = 31 or more hours

• Q7 = Once a week or multiple times every week

Categorize respondents as “Dentists” if their response(s) to

• Q4= Dentist (DDS or DMD)

• Q5 = Dental office

• Q6 = 31 or more hours

• Q7 = Once a week or multiple times every week

Categorize respondents as "Community Pharmacists" if their response(s) to

• Q4 = Pharmacist (PharmD or RPh)

• Q5 = Pharmacy (Retail)

• Q6 = 31 or more hours

• Q7 = Once a week or multiple times every week

Categorize respondents as “Physicians and Advanced Practice Professionals (APPs) in Nursing Homes (NHs)” if their response(s) to

• Q4 = Physician (MD or DO), Physician Assistant (PA), Nurse Practitioner (NP)

• Q5 = Nursing home/Long Term Care

• Q6 = 31 or more hours

• Q7 = Once a week or multiple times every week

Categorize respondents as “Nurses in NHs” if their response(s)

• Q4 = Licensed Nurse (RN, BSN, LPN)

• Q5 = Nursing home/Long Term Care

• Q6 = 31 or more hours

• Q7 = Once a week or multiple times every week

Programmer: If a respondent does not fall into one of the above categories TERMINATE and display the “Ineligibility Message,” else display the “Proceed to Survey Message.”

 

Eligible/Proceed to Survey Message

Thank you for answering the screening questions. We have determined that you are eligible to proceed with this survey. If you have any questions, please contact [name] at [email address] or call phone number XXX-XXX-XXXX or XXX-XXX-XXXX.

Please click on “Proceed to Survey” and answer the questions to the best of your ability.

Ineligibility Message 

Thank you for your willingness to participate in this survey. Unfortunately, you are not eligible to proceed with the survey. If you have any questions, please contact [name] at [email address] or call phone number XXX-XXX-XXXX or XXX-XXX-XXXX.

Thank you for your time. Please click on “Exit Survey” to exit.

baa hcp pre-campaign survey

Exposure to Campaign [ALL]

Programmer: Include one question per page. NOTE**Subheadings within all tables should not be visible to respondents.

Now we would like to ask you about a CDC campaign on appropriate antibiotic use that you may or may not have seen or heard about in the past 12 months.

8. Please indicate below whether you have seen or heard any of the following campaign names or slogans in the past 12 months.

Campaigns	Yes	No	Do not know/ cannot recall
Get Ahead of Antibiotics			
Flip the Script			
Be Antibiotics Aware			
Get Smart About Antibiotics			
Don’t Miss-take Antibiotics			

Programmer: Rotate Q8 (a - e), the column named “Campaigns” among respondents.

9. I n the past 12 months, did you see or hear this slogan/logo (“Be Antibiotics Aware,” “Smart Use, Best Care”) anywhere?

• Yes

• No

• Do not know/cannot recall

Programmer: If the respondent selects “Yes” to Q8c and “Yes” or “Do not know/cannot recall” to Q9, classify as “Exposed” and proceed to the FREQUENCY AND CHANNEL OF EXPOSURE section.

If the respondent selects “Do not know/cannot recall” to Q8c and “Yes” to Q9, classify as “Exposed” and proceed to the FREQUENCY AND CHANNEL OF EXPOSURE section.

If the respondent selects “No” or “Do not know/cannot recall” to Q8c and “No” or “Do not know/cannot recall” to Q9, classify as “Unexposed” and proceed to the KNOWLEDGE section. After the quota of unexposed has been met for each target group then TERMINATE.

Frequency and Channel of Exposure [EXPOSED ONLY]

Programmer: Include one question per page.

You indicated that you had seen or heard the campaign name, Be Antibiotics Aware, or seen the campaign logo in the past 12 months.

10. In the past 12 months, approximately how often did you see CDC’s Be Antibiotics Aware campaign messages, campaign name, or logo in …?

Programmer: Rotate the media options (Poster, Fact sheet, Brochure, etc.).

Printed Media	1-2 times a day	Once a week	1-3 times a month	Less than once a month	Never	Do not know/ cannot recall
Poster						
Fact sheet						
Brochure						
Graphic						
Newspaper/magazine advertisement						
Flyer						
Other print media, please specify: _________________________						

11. In the past 12 months, approximately how often did you see CDC’s Be Antibiotics Aware campaign messages, campaign name, or logo on …?

Programmer: Rotate the media options (Facebook, Instagram, Twitter, etc.).

Social Media	1-2 times a day	Once a week	1-3 times a month	Less than once a month	Never	Do not know/ cannot recall
Facebook						
Instagram						
Twitter						
LinkedIn						
Doximity						
Sermo						
YouTube						
Other social media, please specify: _______________________						

12. In the past 12 months, approximately how often did you see CDC’s Be Antibiotics Aware campaign messages, campaign name, or logo in …?

Programmer: Rotate the media options (Online/Internet Media).

Online/Internet Media	1-2 times a day	Once a week	1-3 times a month	Less than once a month	Never	Do not know/ cannot recall
Health websites /resources (WebMD, Mayo Clinic)						
Video conferencing/ background screen						
Website advertisements						
Online news articles						
Streaming TV/video services (e.g., Hulu, Netflix, [Amazon] Prime Video)						
Streaming internet radio						
Blogs						
Advertisement on mobile phone (including mobile apps)						
Search engines (e.g., Google)						
Others, please specify: _________________________						

13. In the past 12 months, approximately how often did you see or hear CDC’s Be Antibiotics Aware campaign messages, campaign name, or logo on …?

Programmer: Rotate the media options (TV and Radio Media).

TV and Radio Media	1-2 times a day	Once a week	1-3 times a month	Less than once a month	Never	Do not know/ cannot recall
Television (cable, satellite, or antenna)						
Broadcast radio						
Other media formats, please specify: __________________						

14. In the past 12 months, how often did you see CDC’s Be Antibiotics Aware campaign messages, campaign name, or logo in …?

Programmer: Rotate the media options (Public Places).

Public Places	1-2 times a day	Once a week	1-3 times a month	Less than once a month	Never	Do not know/ cannot recall
Billboards						
Bus, train, or subway stations						
On buses or taxi cabs						
Advertisement in a mall						
Advertisement in a grocery store						
Advertisement in a retail pharmacy						
Advertisement at a shopping center or parking lot						
Other public locations, please specify: _________________________						

15. In the past 12 months, did you see CDC’s Be Antibiotics Aware campaign messages, campaign name, or logo at your workplace (including at your home workplace for telework)?

• Yes, I personally placed or shared CDC’s Be Antibiotics Aware Campaign materials at my workplace in the past 12 months.

• Yes, I saw CDC’s Be Antibiotics Aware Campaign at my workplace in the past 12 months, but I was not responsible for placing or sharing it.

• No, but I saw materials from another antibiotic use campaign at my workplace in the past 12 months.

• No, I have not seen any materials about antibiotic use at my workplace in the past 12 months.

Programmer: If the respondent selects “Yes” to Q15, proceed to Q16 else skip Q16 and Q17.

16. In the past 12 months, where did you see CDC’s Be Antibiotics Aware campaign messages, campaign name, or logo at your workplace (including at your home workplace for telework)? Select all that apply.

• Posters or other print material(s) designed to educate patients about appropriate antibiotic use

• Posters or other print material(s) designed to improve antibiotic prescribing by healthcare professionals

• Digital material(s) designed to educate patients about appropriate antibiotic use

• Digital material(s) designed to improve antibiotic prescribing by healthcare professionals

• Video displays in patient waiting areas

• Workplace website or internal email/newsletter

• Email or e-newsletter from an external health organization, such as a state or local public health agency or professional association

• Other, please specify: _________________________________________________________

• Do not know/cannot recall

Programmer: Rotate response options; keep the placement of "Other” and “Do not know/cannot recall" as is.

Programmer: If the respondent selects “Do not know/cannot recall” to Q16, do not allow the respondent to select other responses.

17. You indicated that you saw or heard the campaign name, Be Antibiotics Aware, or saw the campaign logo in the past 12 months. Where did you see or hear it? [Open-ended response]

Programmer: If the respondent selects "Never” or “Do not know/cannot recall” for ALL options in Q10-Q14 and “Yes” to Q15 but selects “Do not know/cannot recall” to Q16, and left Q17 blank, reclassify these respondents as “Unexposed” and proceed to RISKS AND BENEFITS OF ANTIBIOTICS section.

If the respondent selects “1-2 times a day,” “Once a week,” “1-3 times a month,” or “Less than once a month” for any of the options in Q10-Q14, and “Yes” to Q15 or filled in Q17 with more than N/A or None, classify as “Exposed” and proceed to the RISKS AND BENEFITS OF ANTIBIOTICS section.

Risks and Benefits of Antibiotics – Attitudes and Beliefs [ALL GROUPS EXCEPT PHARMACISTS]

Programmer: Include one question per page. Include disclaimer statement below only with Q18. Do not allow participants to go back and change their response to a previous question.

NOTE**Subheadings within all tables should not be visible to respondents.

Next, we are going to ask you some questions to learn more about your perspective on antibiotic prescribing. Research shows that healthcare professionals face challenges with antibiotic prescribing. Your responses to this survey will help CDC understand how to better support healthcare professionals’ antibiotic prescribing habits. Please give us your honest responses. There are no right or wrong answers to any of these questions.

18. Please indicate the extent to which you agree with the following statements, from strongly disagree to strongly agree.

Perceived Severity	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
Antibiotic resistance is a serious public health issue.					
Antibiotic resistance can have serious consequences for my patients.					
Side effects caused by antibiotics could be very serious for my patients.					

19. Please indicate the extent to which you agree with the following statements, from strongly disagree to strongly agree.

Perceived Susceptibility	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
If my patients are prescribed antibiotics, they could experience minor side effects, like a rash.					
If my patients are prescribed antibiotics, they could experience very serious health problems, such as Clostridioides difficile (or C. diff) infection.					

20. Please indicate the extent to which you agree with the following statements, from strongly disagree to strongly agree.

Perceived Benefits	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
Prescribing antibiotics judiciously and only for certain infections caused by bacteria is the best care for my patients.					
Prescribing antibiotics judiciously and only for certain infections caused by bacteria helps protect my patients from unnecessary antibiotic use.					
Prescribing antibiotics judiciously and only for certain infections caused by bacteria helps combat antibiotic resistance.					

21. In the past 12 months, please indicate how often you did the following when prescribing antibiotics.

Behavior (Prescribing)	Never	Rarely	Sometimes	Often	Always
I factor patient satisfaction into my decisions to prescribe antibiotics.					
I prescribe antibiotics according to clinical guidelines.					
I consider antibiotic resistance when prescribing an antibiotic to my patients.					
I take antibiotic resistance into consideration when choosing which antibiotic to prescribe to my patients.					
I consider antibiotic adverse events, like C. diff infection, when prescribing antibiotics to my patients.					

22. What barriers do you commonly experience in prescribing antibiotics to your patients? Select all that apply.

Programmer: Rotate response options; keep placement of “Other,” “I have not encountered any barriers to prescribing antibiotics based on clinical guidelines,” “Do not know/cannot recall,” and “Prefer not to answer” as is.

• Current clinical guidance does not always apply to my patients.

• I am not as familiar as I would like to be with current clinical guidance for prescribing antibiotics.

• My patients will be dissatisfied with their visit if I do not prescribe antibiotics and they believe they need them for their illness.

• My patients demand antibiotics, even if I don’t think an antibiotic is needed to treat their illness.

• My patients are not concerned about antibiotic resistance.

• My patients are unconcerned about potential side effects of antibiotics, such as rash, nausea, or C. diff infection.

• My patients are unaware of potential side effects of antibiotics, such as rash, nausea, or C. diff infection.

• Uncertainty of diagnosis can make it challenging to determine if the patient needs antibiotics.

• Other, please explain: _________________________________________________________

• I have not encountered any barriers to following clinical guidelines regarding antibiotic prescribing.

• Do not know/cannot recall

• Prefer not to answer

Programmer: If the response to Q22 is “I have not encountered any barriers to prescribing antibiotics based on clinical guidelines,” “Do not know/cannot recall,” or “Prefer not to answer,” do not allow the respondent to select other responses.

Risks and Benefits of Antibiotics – Attitudes and Beliefs [PHARMACISTS ONLY]

 

23. Please indicate the extent to which you agree with the following statements, from strongly disagree to strongly agree. 

Perceived Severity	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
Antibiotic resistance is a serious public health issue.
Antibiotic resistance can have serious consequences for my patients.
Side effects caused by antibiotics could be very serious for my patients.

24. Please indicate the extent to which you agree with the following statements, from strongly disagree to strongly agree. 

Perceived Susceptibility	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
If my patients are prescribed antibiotics, whether needed or not needed, they could experience minor side effects, like a rash.
If my patients are prescribed antibiotics, whether needed or not, they could experience very serious health problems, such as Clostridioides difficile (or C. diff) infection.

25. Please indicate the extent to which you agree with the following statements, from strongly disagree to strongly agree.  

Perceived Benefits	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
Providing antibiotics only for certain infections caused by bacteria helps combat antibiotic resistance.

Discussing Antibiotics with Patients: Attitudes, Beliefs and Behaviors [ALL EXCEPT PHARMACISTS]

Programmer: Include one question per page. Do not allow participants to go back and change their answer to a previous question.

26. Please indicate the extent to which you agree with the following statements, from strongly disagree to strongly agree.

Knowledge of Need for Conversations	Strongly Disagree	Disagree	Neither agree nor Disagree	Agree	Strongly Agree
It is important for me to discuss with my patients that antibiotics can cause side effects that can range from minor issues, like a rash, to adverse events, such as C. diff infection.					
It is important for me to discuss with my patients that antibiotic use can contribute to antibiotic resistance.					
It is important for me to help my patients understand ways they can feel better, such as taking over the counter (OTC) medications that can help relieve symptoms, regardless of whether an antibiotic is needed to treat their illness.					
It is important for me to educate patients about when antibiotics are and are not needed for their illness.					

27. Please indicate the extent to which you agree with the following statements, from strongly disagree to strongly agree.

Perceived Benefits of Conversations	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
I believe that educating my patients about appropriate antibiotic use can protect them from unnecessary side effects.					
I believe that educating my patients about appropriate antibiotic use can help reduce unnecessary antibiotic use, thus helping to combat antibiotic resistance.					
I believe that educating my patients about which infections antibiotics do and do not treat helps them understand my decision on whether to prescribe antibiotics for their illness.					

28. When prescribing antibiotics, please indicate how frequently you discuss the following with your patients.

Behavior (Conversations)	Never	Rarely	Sometimes	Often	Always
Whether antibiotics are needed for their illness.					
Other ways to feel better, such as taking OTC medications that can help relieve symptoms, including when a patient has an infection that does not need an antibiotic.					
Common side effects, such as rash, diarrhea, and nausea, when prescribing antibiotics.					
Possible severe side effects, such as C. diff infection or allergic reactions.					
Antibiotic use contributes to antibiotic resistance.					

29. What are the barriers you commonly encounter when educating your patients on the topics of appropriate antibiotic use and antibiotic resistance? Select all that apply.

Programmer: Rotate response options; keep the placement of “Other,” “I have not encountered any barriers to educating my patients on these topics,” “Do not know/cannot recall,” and “Prefer not to answer” as is.

• I am not familiar enough with these topics.

• I do not feel confident educating my patients on these topics.

• I do not think my patients will understand these topics.

• I do not think it is important for my patients to understand these topics.

• I do not think my patients will be interested in or receptive to learning about these topics.

• I do not have time to educate my patients on these topics.

• I do not have access to educational materials about these topics.

• Other, please specify: _____________________________________________________

• I have not encountered any barriers to educating my patients on these topics.

• Do not know/cannot recall

• Prefer not to answer

Programmer: If the response to Q29 is “I have not encountered any barriers to educating my patients on these topics,” “Do not know/cannot recall” or “Prefer not to answer,” do not allow them to select other responses.

30. Did you know that CDC’s Be Antibiotics Aware campaign has resources you can use to help educate your patients about appropriate antibiotic use? 

• Yes 

• No 

Discussing Antibiotics with Patients: Attitudes, Beliefs, and Behaviors [PHARMACISTS ONLY]

31. Please indicate the extent to which you agree with the following statements, from strongly disagree to strongly agree.  

Knowledge of Need for Conversations	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
It’s important for me to discuss with my patients that antibiotics can cause side effects that can range from minor issues, like a rash, to adverse events, such as C. diff infection.
It’s important for me to discuss with my patients that antibiotic use can lead to antibiotic resistance.
It is important for me to help my patients understand ways they can feel better, such as taking over the counter (OTC) medications that can help relieve symptoms, including when an antibiotic is not needed to treat their illness.
It is important for me to educate my patients about when antibiotics are and are not needed for their illness.

32. Please indicate the extent to which you agree with the following statements, from strongly disagree to strongly agree. Educating includes providing verbal or written information on how to take antibiotics correctly.

Perceived Benefits of Conversations	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
I believe that educating my patients about appropriate antibiotic use can protect them from common side effects, such as rash, diarrhea, and nausea.
I believe that educating my patients about appropriate antibiotic use can protect them from more serious side effects, including life-threatening allergic reactions or C. diff infection.
I believe that educating my patients about viral vs. bacterial causes of acute respiratory infections (ARI), including COVID-19, can help reduce unnecessary antibiotic use.
I believe that educating my patients about appropriate antibiotic use can help reduce unnecessary antibiotic use, thus helping to combat antibiotic resistance.

33. When prescribing antibiotics, please indicate how frequently you discuss the following with your patients.

Behavior (Conversations)	Never	Rarely	Sometimes	Often	Always	N/A
Common side effects, such as rash, diarrhea, and nausea.
More serious side effects, such as C. diff infection.
The threat of antibiotic resistance.
The importance of taking antibiotics as prescribed.

34. Did you know that CDC’s Be Antibiotics Aware campaign has resources you can use to help educate your patients about appropriate antibiotic use? 

• Yes 

• No 

Covid-19 Behavior [ALL]

35. In the past 12 months, how often did you feel patients expected you to provide antibiotics because they believed they had COVID-19?

• Always

• Often

• Sometimes

• Rarely

• Never

• Do not know/cannot recall

• I did not see any patients who believed they had COVID-19

36. In the past 12 months, how often did your patients specifically ask for antibiotics because they believed they had COVID-19? 

• Always

• Often

• Sometimes

• Rarely

• Never

• Do not know/cannot recall

• I did not see any patients who believed they had COVID-19

37. In the past 12 months, how often did you provide antibiotics to patients to treat COVID-19?  

• Always

• Often

• Sometimes

• Rarely

• Never

• Do not know/cannot recall

• I did not see any patients who believed they had COVID-19

 

Demographic Characteristics [ALL]

Programmer: Include one set of questions per page.

Thank you. Now we would like to know more about you.

38. How long have you worked as a healthcare professional performing the same duties as your current role?

• Less than one year

• 1-5 years

• 6-9 years

• 10 or more years

• Prefer not to answer

39. What sex were you assigned at birth, on your original birth certificate?

• Male

• Female

• Refused

• I don’t know

40. Do you currently describe yourself as male, female, or transgender?

• Male

• Female

• Transgender

• None of these

41. What is your ethnicity?

• Hispanic or Latino

• Not Hispanic or Latino

42. What is your race?

• American Indian or Alaska Native

• Asian  

• Black or African American  

• Native Hawaiian or Other Pacific Islander  

• White 

End of Survey Message

Thank you for taking the time to participate in this important survey!

Public reporting burden of this collection of information is estimated to average 20 minutes per response, 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