Attachment 2 – PRAMS Instrument to be cognitively tested
Public reporting burden for this collection of information is estimated to average 60 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, MS D-24, Atlanta, GA 30333, ATTN: PRA (0920-0222).
OMB #0920-0222; Expiration Date: 02/28/10
New Questions for Consideration for Phase 6 of the PRAMS Survey
Screening questions to be asked to determine skip patterns
How many children do you have? ____________
What are there ages? ______________
Is your [2-12 month old/fill months old] male or female?
Male
Female
Are you married or living with a partner?
No
Yes
CONCEPTION SPACING
[Note to Interviewer: Ask if R has more than one child]
1. When you got pregnant with your new baby, how old was the child born just before your new baby?
0-12 months
13 to 18 months
19 to 24 months
More than 2 years but less than 3 years
3 to 5 years
More than 5 years
GESTATIONAL DIABETES
2. Before this pregnancy began, were you ever told by a doctor, nurse or other health care provider that you had any kind of diabetes?
No - skip to question 4
Yes
3. Before this pregnancy began, what kind of diabetes were you told you had?
a. Type I or Type II diabetes
b. Gestational diabetes (diabetes during another pregnancy)
c. Both “a” and “b”
4. During this pregnancy, were you told by a doctor, nurse or other health care provider during this pregnancy that you had gestational diabetes?
No - Go to question 9
Yes
5. Since your new baby was born, have you been tested for high blood sugar or diabetes?
No 0- Go to question 9
Yes
6. Since your new baby was born, did a doctor, nurse or other health care provider tell you that you still had diabetes?
No - Go to question 9
Yes
7. When you were told that you had high blood sugar (diabetes), did the doctor, nurse or other health care provider tell you to make an appointment with a different doctor because of your high blood sugar (diabetes)?
No
Yes
8. During this pregnancy, when you were told that you had gestational diabetes, did a doctor, nurse or other health care provider do any of the things listed below?
No Yes
a. Refer you to a nutritionist N Y
b. Talk to you about the importance of exercise N Y
c. Suggest that you breastfeed your new baby N Y
d. Talk to you about staying at a healthy weight after delivery N Y
e. Talk to you about your risk for Type II diabetes…………………………. N Y
FAMILY HISTORY
9. When you were born, were you born more than 3 weeks before your due date?
No
Yes
I don’t know
10. Have any of your close family members who are related to you by blood (grandparents, mother, father, sisters or brothers) ever been treated for any of the problems listed below? For each item, please circle N (no) if no one in your family has been treated for the problem, Y (yes) if someone in your family has been treated for the problem, or DK (don’t know) if you don’t know if anyone in your family has been treated for the problem.
No Yes Don’t Know
a. High blood sugar (diabetes)………………………….. N Y DK
b. Heart problems………………………………………. N Y DK
c. High blood pressure (hypertension)………………….. N Y DK
d. Depression……………………………………………… N Y DK
e. Postpartum depression……………………………………N Y DK
f. Anxiety……………………………………………………….N Y DK
11. Did your mother, any grandmother or any sister who is related to you by blood have any of the following problems during pregnancy? For each item, please circle N (no) if no one in had the problem during pregnancy, Y (yes) if someone had the problem during pregnancy, or DK (don’t know) if you don’t know.
No Yes Don’t Know
a. A baby that was born more than 3 weeks before the due date…… N Y DK
b. High blood sugar or diabetes that started during pregnancy (gestational diabetes)…N Y DK
c. High blood pressure during pregnancy……………………………… N Y DK
INDUCTION OF LABOR
12. Did your doctor, nurse or other health care provider try to induce your labor? That is, did your provider try to cause your labor to begin by the use of drugs or some other technique?
No – Go to question 15
Yes
I don’t know
13. Did the drugs or other techniques that your health care provider used actually start your labor?
No
Yes
I don’t know
14. Why did your doctor, nurse or other health care provider try to start your labor? Check all that apply.
I was past my due date
My water had broken and there was a fear of infection
My provider worried about the size of the baby
My provider was concerned that the baby was not doing well and needed to be born soon
I had a health problem and needed to deliver the baby soon
I wanted to get the pregnancy over with
I wanted to schedule my delivery
I wanted to give birth with a specific provider
I don’t know
Other …………Please tell us:_____________________
POSTPARTUM OBESITY/PREGNANCY WEIGHT GAIN
15. During your most recent pregnancy, did a doctor, nurse or other health worker talk with you about any of the things listed below? Please count only discussions, not reading materials or videos.
Yes No
Foods that are good to eat during pregnancy □ □
How much weight to gain □ □
Exercise during pregnancy □ □
16a. How much weight did you gain during this pregnancy?
___ Pounds OR ___Kilos
□ I LOST weight during this pregnancy
□ I don’t know
16b. How much did your weight change during this pregnancy?
□ I gained ____ pounds or ____kilos
□ I stayed the same
□ I lost _____ pounds or ____kilos
17. How do you feel about your weight now?
□ I am happy with my weight
□ I want to lose weight
□ I want to gain weight
18. Since your new baby was born, how often did you participate in any physical activities or exercise for 30 minutes or more? (For example, walking for exercise, swimming, cycling, dancing, or gardening.) Do not count exercise you may have done as part of your regular job.
□ Less than 1 day per week
□ 1 to 2 days per week
□ 3 to 4 days per week
□ 5 or more days per week
PRETERM LABOR PREVENTION
19. During your most recent pregnancy, did a doctor, nurse or other health care provider give you a drug to keep your baby from being born too early (more than 3 weeks before the due date)? Some drugs that are used to keep the baby from being born early are 17P and progesterone.
No
Yes
I don’t know
[Note to Interviewer: Ask if R is married or living with a partner]
ABUSE
20. During the 12 months before your new baby was born, did you miss any doctor appointments because you were worried about what your partner would do if you went?
No
Yes
21. Before you got pregnant with your new baby, did your husband or partner ever try to keep you from using your birth control so that you would get pregnant when you didn’t want to? For example, did he hide your birth control, throw it away or do anything else to keep you from using it?
No
Yes
FERTILITY TREATMENT
22a. Did you receive treatment from a doctor, nurse, or other health care provider to help you get pregnant with your new baby? (This may include infertility treatments such as fertility-enhancing drugs or assisted reproductive technology).
No Go to Question 25
Yes
22b. How long had you been trying to get pregnant before you took any fertility drugs or used any medical procedures to help you get pregnant with your new baby? Do not count long periods of time when you and your partner were apart or not having sex.
0 to 5 months
6 to 11months
1 to 2 years
More than 2 years to 4 years
More than 4 years to 6 years
More than 6 years
23. Did you become pregnant with your new baby as a result of the treatments listed above?
No => skip next question
Yes
24. How long did you receive fertility treatments before you became pregnant? Do not count times when you had long interruptions in treatment.
0 to 3 months
More than 3 to 6 months
More than 6 to 9 months
More than 9 to 12 months
More than 12 months
BREASTFEEDING SUPPORT
25. Since your new baby was born, have you used WIC services for yourself or your new baby?
No – Go to Question 27
Yes, both my new baby and I use WIC services
Yes, only my new baby uses WIC services
Yes, only I am use WIC services
26. When you went for WIC visits during your most recent pregnancy, did you speak with a breastfeeding peer counselor or another staff person about breastfeeding?
No
Yes
27. Before your new baby was born, did any of the following things happen?
a. Someone answered my questions about breastfeeding
b. I was offered a class on breastfeeding
c. I attended a class on breastfeeding
d. I discussed feeding only breast milk to my baby with my family
e. I discussed feeding only breast milk to my baby with my health care provider
f. I planned to breastfeed within the first hour after giving birth
CESAREAN SECTION
28a. Did you deliver your new baby by cesarean section? (when a doctor cuts through the mother’s belly to bring out the baby)?
No –Go to question 32a
Yes
28b. Whose idea was it for you to have a cesarean delivery? Check one answer.
My health care provider recommended a cesarean delivery before I went into labor.
My health care provider recommended a cesarean delivery while I was in labor.
I wanted the cesarean delivery before I went into labor.
I asked for the cesarean delivery while I was in labor.
29. What was the reason that your new baby was born by cesarean section? Check all that apply.
I had a previous cesarean section
The baby was in the wrong position
I was past my due date
My provider worried that the baby was too big
I had a medical condition that made labor dangerous for me
My age
My weight
Labor was taking too long
The fetal monitor showed that the baby was having problems during labor
I wanted to schedule my delivery
I was afraid to go into labor and have my baby vaginally
I thought it would help me avoid having problems with urine control later in life
I thought it would help me avoid stretching out my vagina
I don’t know
Other reason: Please tell us
30. Had you planned or scheduled a caesarean delivery at least one week before your new baby was born?
No
Yes
31. When did you go to the hospital to deliver your baby?
Before labor started
After labor started
CIRCUMCISION
[Note to interviewer: Ask if R has a male infant 2-12 months old]
32a. Did you have your new baby boy circumcised?
No – Go to Question 33
Yes
32b. What is the reason for having your baby boy circumcised? Check all that apply.
I thought that it was the usual thing to do
The baby’s father wanted the baby circumcised
Religious reasons
I heard that being circumcised can help men avoid diseases such as sexually transmitted diseases and HIV or AIDS later in life
A doctor, nurse or other healthcare provider said that it was a good idea
Other reason=> Please tell us: _____________
FOOD SECURITY
33. In the last 12 months, did you ever get emergency food from a church, a food pantry, or a food bank or eat in a food kitchen?
No
Yes
FOLIC ACID
34a. During your most recent pregnancy, did you take a multivitamin, prenatal vitamin or vitamin containing folic acid in the month before you got pregnant?
No
Yes – Go to question 35
34b. What were your reasons for not taking a multivitamin, prenatal vitamin or vitamin containing folic acid in the month before you got pregnant? Check all that apply.
I wasn’t planning to get pregnant
I didn’t think I needed to take vitamin
The vitamins were too expensive
I didn’t know where to get the vitamins
I didn’t want to take vitamins
35. During the month before you got pregnant with your new baby, did you drink orange juice or eat citrus fruits, broccoli, green leafy vegetables, breakfast cereals, or store-bought bread regularly?
No
Yes
PRECONCEPTION CARE
36a. During the 12 months before you became pregnant with your new baby, did a doctor, nurse or other health worker talk with you about any of the things listed below? Please count only discussions, not reading materials or videos. For each item, circle Y (Yes) if someone talked with you about it or N (No) if no one talked with you about it.
No Yes
Taking a multivitamin with folic acid before pregnancy….N Y
Visiting a dentist or dental hygienist before pregnancy ….N Y
Being a healthy weight before pregnancy……………N Y
Controlling any health conditions such as diabetes and depression before pregnancy………………………………………………………N Y
Getting treatment for any infections before pregnancy….N Y
Getting counseling for diseases that may run in your family…………N Y
How using prescription drugs during pregnancy may affect a baby
How smoking during pregnancy can affect a baby…N Y
How drinking during pregnancy can affect a baby…N Y
PRECONCEPTION READINESS
36b. During the12 months before you became pregnant with your new baby, did you do any of the things listed below? For each item, circle Y (Yes) if you did it or N (No) if you didn’t do it.
No Yes
Take a multivitamin with folic acid most days of the week……….N Y
Visit a dentist or dental hygienist ….N Y
Diet or change eating habits to get to a healthy weight before pregnancy……………N Y
Control any health conditions such as diabetes or high blood pressure
Get counseling for depression or anxiety……………………………N Y
Get treatment for any infections before pregnancy….N Y
Get counseling for diseases that may run in my family…………N Y
Get my vaccinations updated
Cut back or quit smoking …N Y
Cut back or quit drinking alcohol …N Y
POSTPARTUM CARE
37. Since your new baby was born, did a doctor, nurse or other health worker talk with you about any of the things listed below? Please count only discussions, not reading materials or videos. For each item, circle Y (Yes) if someone talked with you about it or N (No) if no one talked with you about it.
No Yes
a. Breastfeeding and how to get help if you needed it …. N Y
b. Healthy eating and exercise……………………………. N Y
c. How long to wait before getting pregnant again….…. N Y
d. Birth control methods that you can use after giving birth……… N Y
e. Postpartum depression……………………………..… N Y
f. Support groups for new parents… N Y
g.Resources in your community such as nurse home visitation programs, telephone hotlines, services for children, etc……………………………… N Y
NEWBORN SCREENING
38. Did you receive counseling or were you informed about sickle disease?
No
Yes
39. Does anyone in your family have sickle cell disease?
No
Yes
I don’t know
SLEEP POSITION
40. Listed below are some things that describe how your new baby sleeps. For each item, circle A (always) if it always applies to your baby, circle S (Sometimes) if it sometimes applies to your baby, or circle N (Never) if it never applies to your baby.
A S N
My new baby sleeps in a crib or portable crib to sleep……….. A S N
My new baby sleeps on his or her back …………….. A S N
My new baby sleeps on a firm mattress ………………………. A S N
My new baby sleeps without pillows, bumper pads,
plush blankets, or stuffed toys A S N
My new baby sleeps alone………………………………… A S N
ENVIRONMENTAL EXPOSURE
41. During your most recent pregnancy, did you work outside of the home at any time?
No Go to Question 44
Yes
42. Did you work with any chemicals, paints, solvents, drugs or inks? Don’t count inks from regular office work unless you were in charge of handling inks or printer cartridges on a regular basis.
No Go to Question 44
Yes
I don’t know
43. During your most recent pregnancy, did you ever feel sick or have an illness that you thought was caused by the chemicals, paints, solvents, drugs or inks in your workplace?
No
Yes
44. Was the house or apartment you live in now built after 1977?
No
Yes Go to Question 46
I don’t know
45. Have you done any of the things listed below since you moved into your house?
I have had the house tested for lead
I have made changes to the house to remove paint or other things that have lead in them
The house was remodeled before I moved in
INSURANCE COVERAGE
46. During the month before you got pregnant with your new baby, were you covered by any of these types of health plans? Check all that apply
Medicaid (state Medicaid name)
Health insurance from a job or that you or someone else paid for
TRICARE or other military health care
State option (IHS, etc.)
State option (state name for indigent care)
I didn’t have any insurance or health plan
Other source => Please tell us
None – Go to Question 49
47. Did any of these kinds of health plans help you pay for your prenatal care? Check all that apply
Medicaid (state name for Medicaid)
Health insurance from a job or that you or someone else paid for
TRICARE or other military health care
I didn’t have a health plan or insurance to help pay for my prenatal care
Other sources Please tell us:
48. Did any of these kinds of health plans help you pay for the delivery of your new baby? Check all that apply
Medicaid (state name for Medicaid)
Health insurance from a job or that you or someone else paid for
TRICARE or other military health care
I didn’t have a health plan or insurance to help pay for my prenatal care
Other sources Please tell us:
49. How tall are you without shoes?
_____ Feet _____Inches
OR _____Meters
50. Did you have any of these problems during your most recent pregnancy? For each item, circle Y (Yes) if you had the problem or circle N (No) if you did not.
No Yes
a. Vaginal bleeding N Y
d. Kidney or bladder (urinary tract) infection N Y
e. Severe nausea, vomiting, or dehydration N Y
f. Cervix had to be sewn shut (incompetent cervix) N Y
g. High
blood pressure, hypertension that started during this pregnancy
(including pregnancy-induced hypertension
[PIH], preeclampsia,
or toxemia) N Y
h. Problems with the placenta (such as abruptio placentae or placenta previa) N Y
[Note to interviewer: If NO to all, go to question 52]
51. Did you do any of the following things because of these problems? For each item, circle Y (Yes) if you did that thing or circle N (No) if you did not.
No Yes
a. I went to the hospital and delivered the baby N Y
b. I went to the hospital or emergency room and stayed less than 1 day, but did not deliver the baby N Y
c. I went to the hospital and stayed 1 to 7 days, but did not deliver the baby N Y
d. I went to the hospital and stayed more than 7 days, but did not deliver the babyN Y
e. I stayed in bed at home more than 2 days because of my doctor’s or nurse’s advice.N Y
52. After your baby was born, how long did he or she stay in the hospital?
Less than 24 hours (less than 1 day)
24 to 48 hours (1 to 2 days)
3 to 5 days
6 days to 14 days
More than 14 days but less than 1 month
1 to 3 months
More than 3 months
My baby did not go to the hospital after he or she was born
My baby is still in the hospital
53. How old was your new baby when he or she completely stopped breastfeeding or being fed breast milk?
_____Days OR _____Weeks OR _____Months
54. How old was your new baby the first time he or she drank liquids other than breast milk such as formula, sugar water, juice water, cow’s milk?
_____[Days OR _____Weeks OR _____Months
My baby has not had any liquids other than besides breast milk
55. How old was your new baby the first time he or she ate baby food, baby cereal or any soft foods?
_____Days OR _____Weeks OR _____Months
My baby has not had any soft foods
56. During the week before your new baby was born, did you expect your baby to be delivered vaginally (naturally) or by cesarean delivery?
Vaginally
Cesarean delivery
DEPRESSION
57. At any time during your most recent pregnancy, did you ask for help for depression from a doctor, nurse, or other health care worker?
No
Yes
58. Since your new baby was born, has a doctor, nurse, or other health care worker told you that you had depression?
No Go to Question 60
Yes
59. Since your new baby was born, did a doctor, nurse or other healthcare provider give you medicine or give you a prescription for medicine for your depression?
No
Yes
Sometimes women have different feelings and experience different emotions after childbirth. Check the choice the best describes how often you have felt the ways listed below.
60. Since your new baby was born, how often have you felt down, depressed or sad?
Always
Often
Sometimes
Rarely
Never
61. Since your new baby was born, how often have you felt hopeless?
Always
Often
Sometimes
Rarely
Never
62. Since your new baby was born, how often have you felt slowed down?
Always
Often
Sometimes
Rarely
Never
ANXIETY
Sometimes women have different feelings and experience different emotions after childbirth. Check the choice the best describes how often you have felt the ways listed below.
63. Since your new baby was born, how often have you felt panicky?
Always
Often
Sometimes
Rarely
Never
64. Since your new baby was born, how often have you felt restless?
Always
Often
Sometimes
Rarely
Never
SAFETY
65. During the 12 months before your new baby was born, how often did you feel unsafe in the neighborhood where you lived?
Always
Often
Sometimes
Rarely Go to Question 67
Never Go to Question 67
66. During the 12 months before your new baby was born, did you do any of the following things because you felt it was unsafe to leave or return to the neighborhood where you lived? Check all that apply.
I missed doctor or other appointments
I limited grocery or other shopping
I stayed with other family members or friends
DENTAL HYGIENE
67. This question is about the care of your teeth during your most recent pregnancy. For each item, circle Y (Yes) if it is true or circle N (No) if it is not true.
No Yes
a. I went to a dentist or dental clinic N Y
b. I needed to see a dentist for a problem N Y
c. A
dental or other health care worker talked with me about how
to
care for my teeth and gums N Y
68. Have you ever had your teeth cleaned by a dentist or dental hygienist?
No Go to Question 70
Yes
69. Did you have your teeth cleaned by a dentist or dental hygienist during the time periods listed below? For each of the three time periods, circle Y (Yes) if you had your teeth cleaned then or circle N (No) if you did not have your teeth cleaned then.
No Yes
a. In the year before my most recent pregnancy N Y
b. During my most recent pregnancy N Y
c. After my most recent pregnancy N Y
SMOKING
70a. Have you smoked at least 100 cigarettes in the past 2 years? (A pack has 20 cigarettes.)
No Go to end
Yes
70b. During any of your prenatal care visits, did a doctor, nurse, or other health care worker advise you to stop smoking?
No
Yes
I had quit smoking before my first prenatal care visit
71.
Listed below are some things about quitting smoking. For each
thing, circle Y (Yes) if it applied to you during your most recent
pregnancy or circle N (No) if it did not.
During your
most recent pregnancy, did you—
a. Set a specific date to stop smoking
b. Use booklets, videos, or other materials to help you quit
c. Call a national or state quit line or go to a website
d. Attend a class or program to stop smoking
e. Go to counseling for help with quitting
f. Use a nicotine patch, gum, lozenge, nasal spray or inhaler
g. Take a pill like Zyban® (also known as Wellbutrin® or Bupropion®) or Chantix® (also known as Varenicline) to stop smoking
h. Tried to quit on your own (e.g., cold turkey)
i. Other: Please tell us: ______________________________________
72. Listed below are some things about quitting smoking that a doctor, nurse, or other health care worker might have done during any of your prenatal care visits. For each thing, circle Y (Yes) if it applied to you during any of your prenatal care visits or circle N (No) if it did not.
During any of your prenatal care visits, did a doctor, nurse, or other health care worker—
No Yes
a. Spend time with you discussing how to quit smoking N Y
b. Suggest that you set a specific date to stop smoking N Y
c. Provide
you with booklets, videos, or other materials to help you quit
smoking on your own N Y
d. Refer you to a national or state quit line N Y
e. Suggest you attend a class or program to stop smoking N Y
f. Refer you to counseling for help with quitting N Y
g. Recommend a nicotine patch, gum, lozenge, nasal spray or inhaler………………. N Y
h. Prescribe a pill like Zyban® (also known as Wellbutrin® or Bupropion®) or Chantix®
(also known as Varenicline) to stop smoking N Y
i. Ask if a family member or friend would support your decision to quit N Y
73. Did you quit smoking?
No - End
74. When did you quit smoking?
Before I found out I was pregnant
When I found out I was pregnant
Later in my pregnancy
| File Type | application/msword |
| File Title | Attachment 2 – PRAMS Instrument to be cognitively tested |
| Author | Karen Whitaker |
| Last Modified By | ziy6 |
| File Modified | 2007-07-26 |
| File Created | 2007-07-26 |