Women's Health Needs STUDY_QUESTIONNAIRE

Form Approved

OMB Number: 0920-XXXX

Expiration Date: XX/XX/XXXX

Public reporting burden of this collection of information is estimated to average 45 minute 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).

SECTION B. BACKGROUND CHARACTERISTICS

Now we can begin. I am going to start by asking you some basic questions about your background.

1. What languages do you speak comfortably now?

A.

B.

C.

2. What language do you speak most often at home (a, b, c, or other - specify)?

• A

• B

• C

• Other, please specify:

3. What language(s) do you speak most often with your closest friends? [INTERVIEWER NOTE: Allow for two languages to be given]

4. If you think of yourself as belonging to a particular ethnic group or tribe, what would that be?

• Don’t Know

• Prefer not to answer

[SKIP LOGIC: IF RESPONDENT WAS BORN IN THE U.S. (SCREENER Q4), GO TO Q7]

5. How long ago did you move to the United States? [INTERVIEWER NOTE: Select best option based on answer for the most recent time]

• Within the last year

• 1-5 years ago

• 6-10 years ago

• Over 10 years ago

• Don’t Know

• Prefer not to answer

6. Since moving to the United States, how many times have you traveled home? “Home country” is the country where you were born or where you lived most of the time before coming to the U.S.

• Never

• Once

  

  ►GO TO Q8

• 2-3 times

• Four or more times

• Don’t know

• Prefer not to answer

7. How many times have you ever traveled outside the U.S.?

• Never

• Once

• 2-3 times

• Four or more times

• Don’t know

• Prefer not to answer

8. In what country does your mother live now?

• Mother passed away [GO TO Q10]

• Don’t Know [GO TO Q10]

• Prefer not to answer [GO TO Q10]

9. How often do you speak with your mother?

• Daily

• 2-3 times a week

• Once a week

• Once/twice a month

• Less than once a month

• Never

• Don’t Know

• Prefer not to answer

SECTION C. MARRIAGE AND HOUSEHOLD

Next, I am going to ask you questions about your marital status and living arrangements.

10. Including yourself, how many people live in your household now? Please count children and elders. Do NOT count people staying in the home for less than one month.

• Don’t Know

• Prefer not to answer

11. Which of the following describes your current marital status? Are you married, living with a partner, widowed, divorced, separated, or have you never been married?

• Married

• Not married, but living with a partner
  [GO TO Q15]

• Widowed

• Divorced

• Separated

• Never married [GO TO Q15]

• Prefer not to answer [GO TO Q15]

12. How old were you when you first got married?

• Under 18 years

• 18-24 years

• 25-29 years

• 30-39 years

• 40-49 years

• Over 49 years

• Don’t Know

• Prefer not to answer

13. How old was your husband when you first got married?

• Under 18 years

• 18-24 years

• 25-29 years

• 30-39 years

• 40-49 years

• Over 49 years

• Don’t Know

• Prefer not to answer

14. In what country did your first marriage take place?

• Don’t Know

• Prefer not to answer

SECTION D. EFFECTS ON MIGRATION

I am now going to ask you some questions about your participation in community activities such as neighborhood organizations or groups.

15. Are you a member of any club or association for people from your family’s home country or ethnic/cultural background?

• Yes

• No

• Not sure

• Prefer not to answer

16. When you invite people to your home, are they usually people from your family’s home country or ethnic/cultural background, or with people who are NOT from your family’s home country or ethnic/cultural background?

• Mostly people from my home country or ethnic/cultural background

• Mostly people NOT from my home country or ethnic/cultural background

• A combination

• I never invite people to my home

• Prefer not to answer

17. Have you done any work outside of the home for pay in the past 30 days?

• Yes

• No

• Don’t Know

• Prefer not to answer

SECTION E. HEALTH-SEEKING BEHAVIOR AND PROVIDER EXPERIENCE

Now I am going to ask you some questions about your overall health and experiences with health care, services, and providers.

18. In general, how would you describe your health? Is it excellent, very good, good, fair, or poor?

• Excellent

• Very good

• Good

• Fair

• Poor

• Not sure

• Prefer not to answer

19. How many times have you gone to a clinic or hospital for health care for yourself in the past 12 months?

• Not at all

• Once

• Twice

• 3-5 times

• More than 5 times

• Don’t Know

• Prefer not to answer

20. When visiting your doctor, would you like to have an interpreter present?

• Yes

• No [GO TO Q23]

• Do not have a doctor [GO TO Q23]

• Don’t Know [GO TO Q23]

• Prefer not to answer [GO TO Q23]

21. During your last visit, was an interpreter offered to you?

• Yes

• No

• Don’t Know

• Prefer not to answer

22. Who usually serves as an interpreter for you?

• My health provider

• Professional interpreter

• A staff person

• A female friend or relative

• My husband or other male relative

• Other, please specify:

• Prefer not to answer

23. Are you currently covered by any of the following types of health insurance?

• A plan purchased through an employer or union (includes plans purchased through another person’s employer)

• A plan that you or a family member buys on their own

• Medicaid or other state or federal program

• Some other source, please specify:

• I do not currently have health insurance

• Don’t Know

• Prefer not to answer

24. During the past 12 months, was there any time when you needed medical care but didn't get it because you couldn't afford it?

• Yes

• No

• Don’t Know

• Prefer not to answer

SECTION F. WOMEN’S HEALTH AND PREGNANCY OUTCOMES

I am now going to ask you questions about family planning and your sexual health.

25. Have you ever used any contraceptives or birth control methods to avoid or delay getting pregnant?

• Yes

• No [GO TO Q27]

• Don’t Know [GO TO Q27]

• Prefer not to answer [GO TO Q27]

26. Which method(s) have you ever used? Have you used this method in the past 30 days?

	Ever Used?	Used in past 30 days?
Female sterilization (tubes tied)	1  Yes 2  No
Male sterilization	1  Yes 2  No
Contraceptive implant (Nexplanon, Jadelle, Sino, Implant, Implanon)	1  Yes 2  No	1  Yes 2  No
IUD (for example, Paragard, Mirena, Skyla, Liletta)	1  Yes 2  No	1  Yes 2  No
Shots/Injections (for example, Depo-Provera)	1  Yes 2  No	1  Yes 2  No
Birth control pills (daily pills, any kind)	1  Yes 2  No	1  Yes 2  No
Contraceptive patch (Ortho Evra, Xulane)	1  Yes 2  No	1  Yes 2  No
Contraceptive ring (NuvaRing)	1  Yes 2  No	1  Yes 2  No
Male condoms	1  Yes 2  No	1  Yes 2  No
Diaphragm	1  Yes 2  No	1  Yes 2  No
Female condoms	1  Yes 2  No	1  Yes 2  No
Foam, jelly, or cream	1  Yes 2  No	1  Yes 2  No
Emergency contraception (morning after pill)	1  Yes 2  No	1  Yes 2  No
Not having sex at certain times (rhythm or natural family planning)	1  Yes 2  No	1  Yes 2  No
Withdrawal (pulling out)	1  Yes 2  No	1  Yes 2  No
Other, please specify:	1  Yes 2  No	1  Yes 2  No

27. In the past 12 months, have you had trouble getting the contraceptives or birth control methods you wanted for any reason?

• Yes

• No [GO TO Q29]

• I did not need a birth control method
  [GO TO Q29]

• Don’t Know [GO TO Q29]

• Prefer not to answer [GO TO Q29]

28. Why did you have trouble getting the birth control method that you wanted?

• Don’t Know

• Prefer not to answer

29. When was your last pelvic exam and/or pap smear?

• Within past year

• 2-3 years ago

• 3 to 5 years ago

• More than 5 years ago

• Never

• Don’t Know

• Prefer not to answer

30. How old were you when you had sexual intercourse for the first time?
    [READ IF NECESSARY: Do not count oral sex, anal sex, heavy petting, or other forms of sexual activity that do not involve vaginal penetration. Do not count sex with a female partner].

• Under 18 years

• 18-24

• 25-29 years

• 30-39 years

• 40-49 years

• Over 49 years

• Never had sexual intercourse
  [GO TO Q39]

• Prefer not to answer

SECTION G. WOMEN’S HEALTH AND PREGNANCY OUTCOMES

To finish up our questions about health and health care, we have a few questions for you about pregnancy and prenatal care.

31. Are you pregnant now?

• Yes

• No [GO TO Q33]

• Don’t Know [GO TO Q33]

• Prefer not to answer [GO TO Q33]

32. Have you had prenatal care for this pregnancy?

• Yes

• No

• Prefer not to answer

Now we have some questions about your children.

33. How many children have you given birth to that were born alive?

[IF 0, GO TO Q39]

• Don’t Know [GO TO Q39]

• Prefer not to answer [GO TO Q39]

Now I will ask a few questions about each child you had beginning with the oldest one.

Child	In what month and year was this child born?	Is this child still alive?	Was this child born in the U.S.?	How many weeks (or months) pregnant were you at the time of your first prenatal care visit?	Was this baby delivered by caesarean section (c-section)?
1	Month: Year:  Prefer not to answer	 Yes  No  Prefer not to answer	 Yes  No [GO TO 39]  Prefer not to answer	 Weeks  Months  No Prenatal Care  Don’t Know  Prefer not to answer	 Yes  No  Prefer not to answer
2	Month: Year:  Prefer not to answer	 Yes  No  Prefer not to answer	 Yes  No [GO TO 39]  Prefer not to answer	 Weeks  Months  No Prenatal Care  Don’t Know  Prefer not to answer	 Yes  No  Prefer not to answer
3	Month: Year:  Prefer not to answer	 Yes  No  Prefer not to answer	 Yes  No [GO TO 39]  Prefer not to answer	 Weeks  Months  No Prenatal Care  Don’t Know  Prefer not to answer	 Yes  No  Prefer not to answer
4	Month: Year:  Prefer not to answer	 Yes  No  Prefer not to answer	 Yes  No [GO TO 39]  Prefer not to answer	 Weeks  Months  No Prenatal Care  Don’t Know  Prefer not to answer	 Yes  No  Prefer not to answer
5	Month: Year:  Prefer not to answer	 Yes  No  Prefer not to answer	 Yes  No [GO TO 39]  Prefer not to answer	 Weeks  Months  No Prenatal Care  Don’t Know  Prefer not to answer	 Yes  No  Prefer not to answer
6	Month: Year:  Prefer not to answer	 Yes  No  Prefer not to answer	 Yes  No [GO TO 39]  Prefer not to answer	 Weeks  Months  No Prenatal Care  Don’t Know  Prefer not to answer	 Yes  No  Prefer not to answer
7	Month: Year:  Prefer not to answer	 Yes  No  Prefer not to answer	 Yes  No [GO TO 39]  Prefer not to answer	 Weeks  Months  No Prenatal Care  Don’t Know  Prefer not to answer	 Yes  No  Prefer not to answer

SECTION H. FGM/C

In a number of countries, there is a practice called circumcision in which a girl or young woman may have part of her genitals cut. Now I would like to ask you some questions about your knowledge and experiences with female circumcision.

39. Do you come from a family that has practiced the tradition of female circumcision?

• Yes, please describe the tradition in your family.

• No

• Don’t Know

• Prefer not to answer

[SKIP LOGIC: IF NOT CURRENTLY MARRIED, GO TO Q41]

40. Does your husband come from a family that has practiced the tradition of female circumcision?

• Yes

• No

• Don’t Know

• Prefer not to answer

41. Have you ever been circumcised?

• Yes

• No [GO TO Q52]

• Don’t Know [GO TO Q52]

• Prefer not to answer [GO TO Q52]

42. What kind of circumcision do you have?

• Prefer not to answer

43. How old were you when first circumcised?

• Less than 1 year old

• 1-4 years old

• 5-9 years old

• 10-14 years old

• 15-19 years old

• More than 19 years old

• Don’t Know

• Prefer not to answer

44. Now I would like to ask you some more questions about your circumcision. Was any flesh removed from the genital area?

• Yes [GO TO Q46]

• No

• Don’t Know

• Prefer not to answer

45. Was the genital area nicked without removing any flesh?

• Yes

• No

• Don’t Know

• Prefer not to answer

46. Was your genital area sewn closed?

• Yes

• No

• Don’t Know

• Prefer not to answer

47. Have you ever had any problems related to your circumcision?

• Yes

• No [GO TO Q49]

• Don’t Know [GO TO Q49]

• Prefer not to answer [GO TO Q49]

48. Please describe what problems occurred.

• Prefer not to answer

49. Would you feel comfortable talking about your circumcision with a health care provider?

• Yes

• No

• Don’t Know

• Prefer not to answer

50. Have you ever talked with a health care provider about your circumcision?

• Yes

• No [GO TO Q52]

• Don’t Know [GO TO Q52]

• Prefer not to answer [GO TO Q52]

51. Who started the conversation about your circumcision, you or the health care provider?

• You

• The health care provider

• Don’t Know

• Prefer not to answer

Have you ever experienced any of these health issues or conditions?

[If Q30=No (Never had sexual intercourse), only ask Items F-J. If reported sexual intercourse for Q30 but Q33=0 (Never had a live birth), only ask items D-J].

Have you ever had a/an. . .?	[Check box if yes]	[if YES] Did you seek professional health care for this?	[if YES] Were you satisfied with how the problem was addressed?	Is this an ongoing problem?
A. Emergency C-section	
B. Postpartum hemorrhage	
C. Extensive vaginal tears from childbirth	
D. Pain with intercourse		 Yes  No  Not treatable by a doctor	 Yes  No	 Yes  No
E. Bleeding with intercourse		 Yes  No  Not treatable by a doctor	 Yes  No	 Yes  No
F. Difficulty passing menstrual blood		 Yes  No  Not treatable by a doctor	 Yes  No	 Yes  No
G. Difficulty passing urine		 Yes  No  Not treatable by a doctor	 Yes  No	 Yes  No
H. Pain with urination		 Yes  No  Not treatable by a doctor	 Yes  No	 Yes  No
I. Recurrent Urinary Tract Infections		 Yes  No  Not treatable by a doctor	 Yes  No	 Yes  No
J. Feeling sad for many weeks at a time		 Yes  No  Not treatable by a doctor	 Yes  No	 Yes  No

<REFER TO RESOURCE HANDOUT TO RESPONDENT FOR COUNSELING AND SUPPORT GROUPS>

SECTION I. FGC BELIEFS

I am now going to ask you some questions about your beliefs and opinions about female circumcision.

53. In your opinion, can female circumcision cause any health problems for women later on (for example during pregnancy and delivery)?

• Yes

• No

• Don’t Know

• Prefer not to answer

[SKIP LOGIC: IF NOT CURRENTLY MARRIED, GO TO Q55]

54. What are your husband’s views about female circumcision? Do you think he would say. . . [INTERVIEWER NOTE: DO NOT READ RESPONSES WHEN ALL CAPS]

• It should be stopped

• It should continue as is

• Depends on the family

• I have mixed feelings about it

• Other, please specify:

• Don’t Know

• Prefer not to answer

55. Which of the following best describes your views about female circumcision? Would you say…

• It should be stopped

• It should continue as is

• Depends on the family

• I have mixed feelings about it

• Other, please specify:

• Don’t Know

• Prefer not to answer

56. Do you believe that female circumcision is required by your religion?

• Yes

• No

• No Religion

• Don’t Know

• Prefer not to answer

<SKIP LOGIC: IF U.S. BORN, GO TO Q59>.

57. Has your opinion about female circumcision changed in any way since you moved to the U.S.?

• Yes

• No [GO TO Q59]

• Not applicable, did not have opinion before moving to U.S. [GO TO Q59]

• Don’t Know [GO TO Q59]

• Prefer not to answer [GO TO Q59]

58. How has your opinion changed?

Probe: Would you say your opinion is:

• More accepting of female circumcision

• Less accepting of female circumcision

• Don’t Know

• Prefer not to answer

SECTION J. EDUCATION

59. What is the highest level of schooling you have completed?

• No formal school

• Less than a high school diploma

• High school diploma or GED

• Some college credit, no degree

• Associate’s degree (for example: AA, AS)

• Bachelor’s degree or higher (for example: BA, BS, MA, MS, MD, PhD, etc)

• Don’t Know

• Prefer not to answer

60. Have you ever attended school in the U.S.?

• Yes

• No [END OF SURVEY]

• Prefer not to answer

61. Are you attending school now?

• Yes

• No

• Prefer not to answer