1 Pre-conception Counseling Community of Practice Retrospe

OMB Number: 0915-XXXX

Expiration Date: 12/31/2026

Public Burden Statement: The evaluation focuses on process and impact evaluation of all CoP Teams. The information collected will inform satisfaction measures (reaction), change in knowledge after the TA (learning), and change in behavior or practice after the introduction of evidence-based interventions (behavior). 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. The OMB control number for this information collection is 0915/0906-XXXX and it is valid until 12/31/2026. This information collection is voluntary. Public reporting burden for this collection of information is estimated to average 0.47 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or [email protected].

1. Pre-Conception Counseling Community of Practice Retrospective Pre-Post-Assessment Instrument

Instructions:

To measure the effectiveness of the Pre-conception Counseling Community of Practice (CoP), we invite you to complete this survey. Through this survey, we are gathering information on both your experience prior to the CoP as well as currently. As you complete the survey, you will notice that we ask you to respond to the questions by first thinking back to beginning of the CoP, and then again by thinking about your experience currently.

The survey will take about 28 minutes to complete.

Your identifying information and survey responses are confidential and will only be seen by the evaluation team. Individual responses will be combined with responses from all other survey participants for reporting purposes. Your honest responses will help us assess the effectiveness of the CoP learning sessions and understand how they may be improved.

1. Type of employment organization: (check one)
Local/State Government Agency
Tribal Organization
Outpatient Behavioral Health Agency
Community Health Center
FQHC/FQHC look-alike
University Medical Center/Hospital
Faith-based Organization
AIDS Service Organization (ASO)
Other

2. Position Title: ___________________________

3. How long have you been in your current position? ___

4. In your current position, do you work directly with patients?

Yes

No

5. What is your age? _____

6. What is your gender identity?

Woman
Man
Transgender
Non-binary
Other

7. Are you Hispanic or Latino?

Yes

No

8. What do you consider yourself to be? (Select one or more.)

Alaska Native

American Indian

Asian

Black or African American

White/Caucasian

Native Hawaiian or Other Pacific Islander

Other

THINK BACK to the beginning of the project. We are interested in knowing how you would have rated your ability AT THAT TIME to do the following:	(5) = Very High	(4) = High	(3) = Medium	(2) = Low	(1) = Very Low	(0) = Not Applicable
9. Provide pre-conception counseling?
10. Talk with patients about their desire to have a child?
11. Help patients to make informed decisions about pregnancy?
12. Provide gender-affirming care for transgender and gender-diverse individuals?

NOW THINK about your work with patients MOST RECENTLY. How would you rate your ability AT THIS TIME to:	(5) = Very High	(4) = High	(3) = Medium	(2) = Low	(1) = Very Low	(0) = Not Applicable
13. Provide pre-conception counseling?
14. Talk with patients about their desire to have a child?
15. Help patients to make informed decisions about pregnancy?
16. Provide gender-affirming care for transgender and gender-diverse individuals?

THINK BACK to the beginning of the project. Please indicate how strongly you WOULD HAVE agreed or disagreed with the following statements about your confidence AT THAT TIME.	(4) = Strongly Agree	(3) = Agree	(2) = Disagree	(1) = Strongly Disagree	(0) = Not Applicable
17. I feel confident in my ability to talk to patients about risk factors for perinatal transmission of HIV and strategies to reduce risk.
18. I do not feel confident initiating a conversation about desire for pregnancy and methods of contraception with my patients.

NOW THINK about your work with patients MOST RECENTLY. Please indicate how strongly you agree or disagree with the following statements about your confidence AT THIS TIME.	(4) = Strongly Agree	(3) = Agree	(2) = Disagree	(1) = Strongly Disagree	(0) = Not Applicable
19. I feel confident in my ability to talk to patients about risk factors for perinatal transmission of HIV and strategies to reduce risk.
20. I do not feel confident initiating a conversation about desire for pregnancy and methods of contraception with my patients.

THINK BACK to the beginning of the project. Please indicate how strongly you WOULD HAVE agreed or disagreed with the following statements about your agency/organization AT THAT TIME.	(4) = Strongly Agree	(3) = Agree	(2) = Disagree	(1) = Strongly Disagree
21. Generally speaking, the staff at my facility has a solid understanding of pre-conception counseling.
22. Our facility has implemented pre-conception counseling protocols.
23. Overall, the staff is supportive of efforts to integrate pre-conception counseling into HIV care.
24. Overall, leadership is supportive of efforts to integrate pre-conception counseling into HIV care.

NOW THINK about your agency/organization MOST RECENTLY. Please indicate how strongly you agree or disagree with the following statements about the agency/organization.	(4) = Strongly Agree	(3) = Agree	(2) = Disagree	(1) = Strongly Disagree
25. Generally speaking, the staff at my facility has a solid understanding of pre-conception counseling.
26. Our facility has implemented pre-conception counseling protocols.
27. Overall, the staff is supportive of efforts to integrate pre-conception counseling into HIV care.
28. Overall, leadership is supportive of efforts to integrate pre-conception counseling into HIV care.

THINK BACK to the beginning of the project. Please indicate how strongly you WOULD HAVE agreed or disagreed with the following statements AT THAT TIME.	(4) = Strongly Agree	(3) = Agree	(2) = Disagree		(1) = Strongly Disagree		(0) Not Applicable
29. I regularly provide pre-conception counseling.
30. I have a good understanding of HIV treatment regimens for pregnant women.
31. I can identify risk factors for adverse material or fetal outcomes.
32. I have a good understanding of strategies to reduce the risk of mother-to-child transmission of HIV.

NOW THINK about your work with patients MOST RECENTLY. Please indicate how strongly you agree or disagree with the following statements AT THIS TIME.	(4) = Strongly Agree	(3) = Agree	(2) = Disagree		(1) = Strongly Disagree		(0) Not Applicable
33. I regularly provide pre-conception counseling.
34. I have a good understanding of HIV treatment regimens for pregnant women.
35. I can identify risk factors for adverse material or fetal outcomes.
36. I have a good understanding of strategies to reduce the risk of mother-to-child transmission of HIV.

THINK BACK to the beginning of the project. We are interested in how you thought the CoP would impact you personally. Please tell us about your expectations AT THAT TIME. To what extent did you expect that:	(5) = Greatly	(4) = Somewhat	(3) = Undecided	(2) = Very Little	(1) = Not At All
37. You would be satisfied with your experience.
38. Your collaborative network would expand.
39. Your knowledge of pre-conception counseling would increase.
40. Your knowledge of best practices would increase.
41. Your capacity to perform your work would increase.
42. Participation would provide new ways of doing your job.
43. The CoP would meet its goals.
44. Your ability to develop productive collaborations would increase.
45. Your learning expectations would be met.
46. Your networking experiences would increase.
47. Your work would change as a result of your experience.
48. You would take action on ideas that were generated as a result of your work with the CoP.

NOW THINK about how the CoP has impacted you MOST RECENTLY. Please tell us about your experience.	(5) = Greatly	(4) = Somewhat	(3) = Undecided	(2) = Very Little	(1) = Not At All
49. I am satisfied with my experience.
50. My collaborative network expanded.
51. My knowledge of pre-conception counseling increased.
52. My knowledge of best practices increased.
53. My capacity to perform my work increased.
54. Participation provided new ways of doing my job.
55. The CoP met its goals.
56. My ability to develop productive collaborations increased.
57. My learning expectations have been met.
58. My networking experiences increased.
59. My work changed as a result of my experience.
60. I have taken action on ideas that were generated as a result of my work with the CoP.

61. As a result of the CoP, did your facility implement a new evidence-based, evidence-informed, or emerging intervention/practice?

Yes (continue to 62)

No (skip to 64)

Don’t Know/Not Sure (skip to 64)

62. What is the name of the intervention or practice that was implemented?

63. How closely did you adhere to the standard program or intervention model?

To a Great Extent
Somewhat
Very Little
Not at All
Don’t Know/Not Sure

We would like to have a deeper understanding of your experiences. Please respond to the following questions:

64. What was the most effective part of the CoP?

65. What did you learn that will help you perform better in your role?

66. How have you put what you learned in this CoP to use?

67. Has participation in this CoP resulted in changes in your collaborations or partnerships? If so, please describe.

68. Has participation in this CoP helped you achieve your goals related to (pre-conception counseling)? Why/why not?

69. How can Bizzell improve the implementation of CoP?