3 Participant Survey
Healthy Start Evaluation and Capacity Building Support
Attachment B3_HS Participant Survey
OMB: 0906-0076
Attachment B3
Healthy Start Participant Survey
HRSA’s Healthy Start Evaluation and Capacity Building Support Project
October 2022
|
HRSA’s Healthy Start Evaluation and Capacity Building Support Project
Healthy Start Participant Survey
Funding for data collection supported by the Maternal and Child Health Bureau (MCHB) Health Resources and Services Administration (HRSA) U.S. Department of Health and Human Services |
Public Burden Statement: This data collection will provide the Health Resources and Services Administration with information to guide future program decisions regarding the Healthy Start program’s effectiveness on individual, organizational, and community-level outcomes. 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 xxxx-XXXX and it is valid until XX/XX/202X. This information collection is voluntary. The current project will fully comply with the Privacy Act of 1974 (5 U.S.C. Section 552a, 1998; https://www.justice.gov/opcl/privacy-act-1974). The Privacy Act may apply to some data collection activities (e.g., the study will collect email addresses from some respondents). Public reporting burden for this collection of information is estimated to average xx hours per response, including the time for reviewing instructions and completing 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 paperwork@hrsa.gov.
Welcome!
This is a survey about the Healthy Start Program. We are inviting you to answer the questions in the survey because we want to know if Healthy Start is helpful for you.
Your answers to the survey are very important to us. They will help us know how well the Healthy Start program is doing in supporting families before, during, and after pregnancy.
The survey will take about 15 minutes to finish. There are no right or wrong answers. Your answers are private. We will not share your answers with your case manager or any Healthy Start staff.
Questions? Email any questions to HSEvalSupport@westat.com.
Click “Next” to proceed.
Informed Consent
This survey is voluntary. You don’t have to respond to it if you don’t want to. Your decision to do or not do the survey won’t affect your Healthy Start services. You may also choose to skip a question or stop the survey at any time.
There are no known risks to you for taking part in this survey. Your answers will remain private. There are also no direct benefits to you for taking part in this survey, but your answers will help us understand how to improve the Healthy Start program. We won’t identify any individual in the reports that we write about the survey results.
If you have any questions about this survey, please contact Westat at 1800xxxx or email HSEvalSupport@westat.com. Westat is the company doing the survey. The Health Resources and Services Administration, or HRSA, is funding the Healthy Start program, and hired Westat to survey Healthy Start participants to find out how well the Healthy Start program meets your needs. HRSA is a federal government agency and offers programs for improving access to health care services for people who are uninsured, isolated, or medically vulnerable.
Do you have questions about privacy or other issues about doing a survey? Please call Westat’s survey office at 1-888-920-7631. Leave a message with your name and number. Say you are calling about the Healthy Start survey. They will call you back.
To do the survey, click “I agree to do this survey.” If you don’t want to do the survey, click “I do not agree to do this survey.”
I agree to do this survey
I do not agree to do this survey
Directions
The survey will take about 15 minutes to finish. Once you start the survey, please try to finish the entire survey without stopping. If you need to stop the survey for longer than 20 minutes, please save your answers first.
Please select the box next to your answer, and follow the directions next to the question. Some questions may be skipped if they don’t apply to you.
If you have been in Healthy Start before, please answer just about your experience for this enrollment period (April 2019 and after).
SECTION I. BACKGROUND
1. a. Are you currently enrolled in the Healthy Start program? [REQUIRED]
Yes
No GO TO END TO THANK THE RESPONDENT
b. Please select the name of your Healthy Start program. [REQUIRED]
[DROPDOWN MENU OF 15 PROGRAM NAMES (CITY, STATE)]
I’m not sure
2. Are you 18 years or older? [REQUIRED]
Yes
No GO TO END TO THANK THE RESPONDENT
3. How long have you been in the Healthy Start program? If you have enrolled in this program more than once, please respond based on your current experience. Select one only.
Less than 1 month
1 month to less than 3 months
3 months to less than 1 year
1 year to less than 2 years
2 years to less than 3 years
More than 3 years
4. How would you describe your gender? Select one only.
Female
Male
Prefer to self-describe ____________________________________
5. When you signed up for Healthy Start during this enrollment period, were you _______? Please read ALL options and select one only. [REQUIRED]
Not pregnant
Pregnant
Postpartum – Not pregnant, but gave birth in the 3 months before I enrolled in Healthy Start
Postpartum – Not pregnant, but gave birth 3 months to 1 year before I enrolled in Healthy Start
A partner to a woman enrolled in Healthy Start or a father to a child enrolled in Healthy Start GO TO SECTION III
Other (Please Explain): (Character limit: 200)
SECTION II. HEALTHY START SERVICES
This section asks about your Healthy Start services and what you thought of them.
6. Do you have a Healthy Start case manager/community health worker? (In the following questions, this role will be referred to as case manager.)
Yes
No
7. Was the information and education that you received from Healthy Start helpful?
Yes
No. If no, please explain ___________________ (Character limit: 300)
8. Did Healthy Start staff refer you to SNAP (Supplemental Nutrition Assistance Program)? SNAP is a federal government program that helps people with low or no income to purchase food. In the past, this was known as “food stamps”.
I didn’t need SNAP benefits; I already had SNAP SKIP TO QUESTION 11
Yes, Healthy Start referred me
No, Healthy Start didn’t refer me
9. Did you apply for SNAP?
Yes, I applied and got benefits SKIP TO QUESTION 11
Yes, I applied but I am waiting to hear back SKIP TO QUESTION 11
Yes, I applied but I wasn’t eligible SKIP TO QUESTION 11
No, I didn’t apply
10. What were the reasons you did not apply for SNAP? (Check all that apply)
I was worried that SNAP would affect my other benefits
I didn’t think I needed it
I didn’t know how to apply
I didn’t think I would be eligible
11. Did Healthy Start refer you to WIC (Special Supplemental Nutrition Program for Women, Infants, and Children)?
I didn’t need WIC benefits; I already had WIC SKIP TO QUESTION 14
Yes, Healthy Start referred me
No, Healthy Start didn’t refer me
12. Did you apply for WIC?
Yes, I applied and enrolled in the program SKIP TO QUESTION 14
Yes, I applied but I am waiting to hear back SKIP TO QUESTION 14
Yes, I applied but I wasn’t eligible SKIP TO QUESTION 14
No, I didn’t apply
13. What were your reasons you did not apply for WIC? (Check all that apply)
I was worried that WIC would affect my other benefits
I didn’t think I needed it
I didn’t live near a WIC site
I didn’t know how to apply
I didn’t think I would be eligible
I didn’t have time
14. Did Healthy Start staff refer you to Medicaid?
I didn’t need Medicaid benefits; I already had Medicaid SKIP TO QUESTION 18
Yes, Healthy Start referred me
No, Healthy Start didn’t refer me
15. Did you apply for Medicaid?
Yes, I applied and enrolled in the program
Yes, I applied but I am waiting to hear back
Yes, I applied but I wasn’t eligible
No, I didn’t apply SKIP TO QUESTION 17
16. Did Healthy Start staff help you with your Medicaid application?
Yes SKIP TO QUESTION 18
No SKIP TO QUESTION 18
17. What were the reasons you did not apply for Medicaid? (Check all that apply)
I had other insurance
I didn’t know how to apply
I didn’t think I would be eligible
I was worried that Medicaid would affect my other benefits
I didn’t think I needed it
I didn’t have time
18. Did Healthy Start staff refer you to TANF (Temporary Assistance to Needy Families program)? TANF is a federally-funded program that provides cash assistance to help families meet their basic needs. In the past, this was known as welfare.
I didn’t need TANF benefits; I already had TANF SKIP TO QUESTION 21
Yes, Healthy Start referred me
No, Healthy Start didn’t refer me
19. Did you apply for TANF?
Yes, I applied and got benefits SKIP TO QUESTION 21
Yes, I applied but I am waiting to hear back SKIP TO QUESTION 21
Yes, I applied but I wasn’t eligible SKIP TO QUESTION 21
No, I didn’t apply
20. What were the reasons you did not apply for TANF? (Check all that apply)
I was worried that TANF would affect my other benefits
I didn’t think I needed it
I didn’t know how to apply
I didn’t think I would be eligible
I didn’t have time
21. a. Did Healthy Start staff refer you to any of the following services outside Healthy Start? Select “Yes” or “No” per row.
-
Service
Healthy Start referred me
(YES/NO)a. Breastfeeding/lactation support
Yes No
b. Child care
Yes No
c. Domestic/family or intimate partner violence
Yes No
d. Doula
Yes No
e. Family planning/birth control
Yes No
f. Home visiting programs
Yes No
g. Mental health (such as for depression, anxiety, stress)
Yes No
h. Other mental health services
Yes No
i. Primary care/Basic healthcare for women
Yes No
j. Primary/Pediatric care for child
Yes No
k. Quitting smoking
Yes No
l. Substance abuse, drugs, alcohol treatment
Yes No
m. Other (Please Explain):
(Character limit: 200)
Yes No
b. Did you receive any of the following services that Healthy Start staff referred you to? Select “Yes” or “No” per row. [THIS QUESTION WILL BE PREPOPULATED TO SHOW ONLY THE RESPONSES SELECTED IN 21.a. AND WILL BE SKIPPED IF NO RESPONSES SELECTED IN 21.a.]
-
Service
I received this service
(YES/NO)a. Breastfeeding/lactation support
Yes No
b. Child care
Yes No
c. Domestic/family or intimate partner violence
Yes No
d. Doula
Yes No
e. Family planning/birth control
Yes No
f. Home visiting programs
Yes No
g. Mental health (such as for depression, anxiety, stress)
Yes No
h. Other mental health services
Yes No
i. Primary care for women
Yes No
j. Primary/Pediatric care for child
Yes No
k. Quitting smoking
Yes No
l. Substance abuse, drugs, alcohol treatment
Yes No
m. Other (Please Explain):
(Character limit: 200)
Yes No
22. a. Did Healthy Start staff refer you to any of the following services or programs outside Healthy Start? Select “Yes” or “No” per row.
-
Service
Healthy Start referred me
(YES/NO)a. Education
Yes No
b. Job services/job training
Yes No
c. Housing or home heating services
Yes No
d. Immigration
Yes No
e. Legal services
Yes No
b. Did you receive any of the following services that Healthy Start staff referred you to? Select “Yes” or “No” per row. [THIS QUESTION WILL BE PREPOPULATED TO SHOW ONLY THE RESPONSES SELECTED IN 22.a. AND WILL BE SKIPPED IF NO RESPONSES SELECTED IN 22.a.]
-
Service
I received the service
(YES/NO)a. Education
Yes No
b. Job services/job training
Yes No
c. Housing or other home-related services
Yes No
d. Immigration
Yes No
e. Legal services
Yes No
23. How satisfied are you with the services and support you received from Healthy Start staff?
Very dissatisfied
Dissatisfied
Satisfied
Very satisfied
(Please Explain):
(Character limit: 300)
24. Do you think that the services and support you have received from Healthy Start staff have taken into account your culture and traditions?
Yes
(Character limit: 300)
25. How often have you been able to reach your Healthy Start case manager when you need to?
Almost never
Less than half the time
About half of the time
More than half the time
Almost all of the time
26. What have been the most helpful parts of Healthy Start for you? (Check all that apply)
Having a case manager
Learning about health
Learning about parenting
Getting referrals to community services and programs
Meeting other program participants
Other (Please Explain): (Character limit: 200)
27. What changes would you make to improve Healthy Start?
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(Character limit: 500)
GO TO SECTION IV
SECTION III. HEALTHY START FATHER/PARTNER INVOLVEMENT
Answer the questions in this section ONLY if you are a father or partner of a Healthy Start participant. If you have participated in Healthy Start before, please answer the questions only for this enrollment period (April 2019 and after).
28. At the time you began participating in Healthy Start, was your partner? Please read ALL options and select one only.
Not pregnant
Pregnant
Postpartum – Not pregnant, but gave birth in the 3 months before I enrolled in Healthy Start
Postpartum – Not pregnant, but gave birth 3 months to 1 year before I enrolled in Healthy Start
Other (Please Explain): (Character limit: 200)
29. What activities have you participated in as a father/partner? Check all that apply.
Going to partner’s healthcare appointments
Going to child’s healthcare appointments
Meetings or calls with my Healthy Start case manager /community health worker? (In the following questions, this role will be referred to as case manager)
Healthy Start support group(s)
Healthy Start health education or other sessions
Healthy Start Community Action Network (CAN) meetings
Healthy Start community events
Other (Please Explain): (Character limit: 200)
30. a. Did Healthy Start staff provide information on the following activities? Select “Yes” or “No” per row.
-
Information
Information given?
(YES/NO)a. Healthy relationships
Yes No
b. Relationship-building with the mother or co-parent
Yes No
c. Co-parenting
Yes No
d. Interpersonal skills
Yes No
e. Dealing with trauma
Yes No
f. Anger management
Yes No
g. Financial/money issues
Yes No
h. Custody information/other legal issues
Yes No
i. Health issues
Yes No
j. Other (Please Explain):
(Character limit: 200)
Yes No
b. Was the information provided by the Healthy Start staff on these activities helpful? Select “Yes,” “No,” or “Not Applicable” per row.
[THIS QUESTION WILL BE PREPOPULATED TO SHOW ONLY THE RESPONSES SELECTED IN 30.a. AND WILL BE SKIPPED IF NO RESPONSES SELECTED IN 30.a.]
-
Information
Information helpful?
(YES/NO)Not applicable
a. Healthy relationships
Yes No
b. Relationship-building with the mother
Yes No
c. Co-parenting
Yes No
d. Interpersonal skills
Yes No
e. Overcoming trauma
Yes No
f. Anger management
Yes No
g. Financial/money issues
Yes No
h. Custody information/other legal issues
Yes No
i. Health issues
Yes No
j. Other (Please Explain):
(Character limit: 200)
Yes No
31. Was there information that Healthy Start staff did not provide that you would have liked to receive?
Yes (Please Explain): (Character limit: 200)
No
32. a. Did Healthy Start staff refer you to any of the following services? Select “Yes” or “No” per row.
-
Service
Healthy Start referred me
(YES/NO)a. Domestic/family or intimate partner violence
Yes No
b. Housing/home heating
Yes No
c. Immigration
Yes No
d. Job services/job training
Yes No
e. Legal
Yes No
f. Medicaid
Yes No
g. Medical
Yes No
h. Mental health
Yes No
i. Substance abuse, alcohol, drug treatment
Yes No
j. Quitting smoking
Yes No
k. SNAP (Supplemental Nutrition Assistance Program)
Yes No
l. TANF (Temporary Assistance to Needy Families program)
Yes No
m. Other (Please Explain):
(Character limit: 200)
Yes No
b. Did you receive any of the services that Healthy Start referred you to? Select “Yes” or “No” per row.
[THIS QUESTION WILL BE PREPOPULATED TO SHOW ONLY THE RESPONSES SELECTED IN 32.a. AND WILL BE SKIPPED IF NO RESPONSES SELECTED IN 32.a.]
-
Service
I received this service
(YES/NO)a. Domestic/family or intimate partner violence
Yes No
b. Housing/home heating
Yes No
c. Immigration
Yes No
d. Job services/job training
Yes No
e. Legal
Yes No
f. Medicaid
Yes No
g. Medical
Yes No
h. Mental health
Yes No
i. Substance abuse, alcohol, drug treatment
Yes No
j. Quitting smoking
Yes No
k. SNAP (Supplemental Nutrition Assistance Program)
Yes No
l. TANF (Temporary Assistance to Needy Families program)
Yes No
m. Other (Please Explain):
(Character limit: 200)
Yes No
SKIP NEXT QUESTION IF YES IS CHECKED FOR ALL RESPONSES IN 32.b.
33. Use the list below to describe the reason(s) you did not receive the services that Healthy Start referred you to. Check ALL of the reason(s) that you did not receive the services.
I didn’t think I needed this service
I didn’t have time
I didn’t have transportation
I didn’t have childcare
I didn’t have anyone to help with interpreter services and translation
I didn’t know where to go
I couldn’t pay for the service
I didn’t trust the organization I was referred to
I wasn’t eligible for the service
Other (Please describe the other reasons you didn’t receive the services)
(Character limit: 200)
34. Do you have a Healthy Start case manager who works with you?
Yes
No SKIP TO QUESTION 36
35. How often have you been able to reach your Healthy Start case manager when you need to?
Almost never
Less than half the time
About half of the time
More than half the time
Almost all of the time
36. How satisfied have you been with the services and support that you received from the Healthy Start program?
Very dissatisfied
Dissatisfied
Satisfied
Very satisfied
(Please Explain):
(Character limit: 300)
37. Do you think that the services and support you have received from Healthy Start staff have taken into account your culture and traditions?
Yes
(Character limit: 300)
38. What have been the most helpful parts of Healthy Start for you? (Check all that apply)
Having a case manager
Learning about health topics
Learning about parenting
Healthy Start referrals to community services and programs that I needed
Involvement with other fathers/male partners
The program was not helpful for me
39. What about Healthy Start has helped you be a more supportive partner? Check all that apply.
Working with a case manager
Learning about health topics
Learning about parenting
Healthy Start referrals to community services and programs that I needed
Involvement with other male partners
Healthy Start didn’t help me to be a more supportive partner
Not applicable because I am not a partner
40. What about Healthy Start has helped you be a better parent? Check all that apply.
Working with a case manager
Learning about health topics
Learning about parenting
Healthy Start referrals to community services and programs that I needed
Involvement with other male partners
Healthy Start didn’t help me to be a better parent
Not applicable because I am not a parent
41. What changes would you make to improve Healthy Start?
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(Character limit: 500)
SECTION IV. HEALTH EQUITY
In this section, we would like to get your thoughts and experiences with Healthy Start around health equity. We have included one organization’s definition of health equity below for your reference and consideration.
Health equity means that everyone has a fair and just opportunity to be as healthy as possible. This requires removing barriers/obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care.
42. Do you think that Healthy Start helps contribute to improving health equity for the people it serves?
Yes
No
43. How often have you experienced any type of bias, such as discrimination due to race, ethnicity, level of ability, income, etc., when getting healthcare or social services?
Never
Sometimes
Often
Very often
44. Has Healthy Start made it easier or more comfortable for you to receive healthcare or social services?
Yes
No
45. In what ways has Healthy Start made it easier for you to receive healthcare services (such as prenatal care) or social services (such as housing or job assistance)? Please briefly describe up to three ways that Healthy Start has promoted health equity for you personally, or ways that the program has helped remove barriers to receiving healthcare or social services.
a.
b.
c.
(Character limit: 500)
46. What more do you think Healthy Start can do to reduce the bias in health services and social services in your community?
|
(Character limit: 500)
SECTION V. ADDITIONAL INFORMATION
Finally, please answer a few questions about you.
47. What state do you live in?
SELECT FROM DROP DOWN LIST OF STATES
48. How old are you (in years)?
49. Are you Hispanic/Latino?
Yes
No
Prefer not to answer
50. What is your race? (Check all that apply)
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other (Please Explain): (Character limit: 200)
Prefer not to answer
51. What is the language you are most comfortable speaking?
English
Spanish
French
German
Russian
Chinese (including Cantonese, Mandarin, and other varieties)
Tagalog
Korean
Vietnamese
Arabic
Other (Please Explain): (Character limit: 200)
52. Did you get interpreter or translation services from Healthy Start? (Check all that apply)
Yes
No, but I needed it
No, I bring a family member or friend to interpret for me
I don’t need these services because I am fluent in English
53. What is your current marital status?
Never married
Partnered, but not married
Married
Separated
Divorced
Widowed
Other (Please Explain): (Character limit: 200)
54. What was the highest level of school you completed?
No formal schooling
8th grade or less
Some high school (grades 9, 10, 11, 12)
High school diploma (completed 12th grade)
GED
Some college or 2-year degree
Technical or trade school
Bachelor’s degree
Graduate or professional school
Prefer not to answer
55. Which best describes your current job situation? (SELECT ONE ANSWER)
Have a full-time job
Have a part-time job or seasonal job
Have multiple part-time jobs
Not employed – caregiver/homemaker
Not employed – unable to work due to health or disability
Not employed – unable to find work
Not employed – student
Other (Please Explain): (Character limit: 200)
Prefer not to answer
56. How difficult has it been to continue participating in your Healthy Start program?
It hasn’t been difficult at all
It’s been a little difficult
It’s been moderately difficult
It’s been extremely difficult
(Please Explain):
(Character limit: 200)
57. How did the COVID pandemic affect your participation in Healthy Start and other services? Check all that apply.
I didn’t have my regular in-person visits with my Healthy Start case manager
I did all or most of my visits with my case manager on the telephone and/or the computer
I didn’t have regular in-person visits with my doctor or nurse
I did all or most of my visits with my doctor or nurse on the telephone and/or the computer
I didn’t have in-person visits with my child’s doctor or nurse
I did all or most of my child’s visits with their doctor or nurse on the telephone and/or the computer
I didn’t get the tests/vaccinations that I needed for myself and my child on time
I didn’t go to other medical or social service appointments that I usually go to
Other (Please Explain): (Character limit: 200)
58. How satisfied were you with the telehealth/virtual care you received during the COVID pandemic? Select one.
Very dissatisfied
Dissatisfied
Satisfied
Very satisfied
(Please Explain):
(Character limit: 200)
I didn’t receive telehealth/virtual care during the pandemic
59. What were your greatest challenges during the pandemic?
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(Character limit: 500)
Thank you for completing the survey.
Please press SEND to submit the survey.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Saloni Sapru |
| File Modified | 0000-00-00 |
| File Created | 2023-09-10 |
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