Tab 7
BASELINE ACASI SURVEY (Phase 2 Study)
Flesh-Kincaid 7.0
INTERVIEWER READ:
Thank you for agreeing to talk with me today. This interview is going to cover many topics, including your health and your experiences with HIV medical care. This information will help us to improve care for people living with HIV.
Everything that we are going to talk about is confidential. If there are any questions you don’t feel comfortable answering, you don’t have to answer them.
This interview will take about 30 minutes. As I go through the questions, please let me know if there is anything that is unclear. Are you ready to begin?
Demographics
1. What is your month and year of birth?
Month: ____ ____ (Select a month Jan through Dec from the dropdown menu)
Year: ____ ____ ____ ____ (Select a year from the dropdown menu)
2. What is your gender?
Male
Female
Transgender or transsexual (Male to Female)
Transgender or transsexual (Female to Male)
3. What race do you consider yourself to be? (Choose ALL groups that describe your race)
White
Black or African- American
American Indian or Alaska Native
Asian
Native Hawaiian or other Pacific Islander
4. What is your ethnicity? Choose one.
Hispanic or Latino
Not Hispanic or Latino
5. Where were you born?
In the United States of America, Puerto Rico, or other U.S. territory (for example, U.S. Virgin Islands, Guam, or Northern Mariana Islands)
In another country
6. What language do you speak most of the time, with friends and family?
English
Spanish
French
Haitian Creole
Portuguese
Chinese
Vietnamese
Other
7. How much school have you completed?
8th grade or less
Some high school
High school graduate/GED
Some college
4-year college graduate
Graduate school or professional degree
8. Are you currently married or in a marriage-like or committed relationship?
Yes
No
9. What is your sexual orientation?
Heterosexual/Straight
Homosexual/Gay
Homosexual/Lesbian
Bisexual
10. In the past 2 years, with whom have you had sex?
Men only
Women only
Both men and women
Nobody
11. Where do you live? (Choose one)
In my own home/apartment
In someone else’s home/apartment
Supported/transitional housing
Shelter
Residential treatment program
The streets/in a car/in a park/on the beach
In an abandoned building
Motel
Foster/group home
Boarding house/Single room occupancy (SRO)
Correctional facility
Moving from house to house; I have no permanent place to stay
Other
12. Are you the primary caregiver for any of the following:
A primary caregiver is someone who provides the most care or who assumes the most responsibility for another person.
a. Are you the primary caregiver for any children?
Yes
No
b. Are you the primary caregiver for any adults, including any elderly person(s)?
Yes
No
13. At any time in the past 30 days, did you work at a paying job?
No, I did not work at a paying job
Yes, I worked at a paying job 1 – 10 hours per week
Yes, I worked at a paying job 11 – 30 hours per week
Yes, I worked at a paying job more than 30 hours per week
14. What is the easiest way for you to tell me your (household) income?
__ Weekly
__ Every other week or twice a month
__ Monthly
__ Yearly
15. What is your combined household income from all sources?
This is the amount of money you take home on a [insert time period indicated in the previous question] basis.
$ ______________________________
16. How many people depend on this income?
Myself only
Myself and 1 other person
Myself and 2 other persons
Myself and 3 or more persons
Health-related Quality of Life (SF-1)
1. In general, would you say your health is:
Excellent
Very good
Good
Fair
Poor
Life Chaos
INTERVIEWER READ: The following statements are about your life in general. Please tell me how much you agree or disagree with each statement.
1. My life is organized
Strongly agree
Somewhat agree
Somewhat disagree
Strongly disagree
2. My life is unstable
Strongly agree
Somewhat agree
Somewhat disagree
Strongly disagree
3. My routine is the same from week to week
Strongly agree
Somewhat agree
Somewhat disagree
Strongly disagree
4. My daily activities from week to week are unpredictable
Strongly agree
Somewhat agree
Somewhat disagree
Strongly disagree
5. Keeping a schedule is difficult for me
Strongly agree
Somewhat agree
Somewhat disagree
Strongly disagree
6. I do not like to make appointments too far in advance because I do not know what might come up
Strongly agree
Somewhat agree
Somewhat disagree
Strongly disagree
HIV Stigma
INTERVIEWER READ: The following statements are about some of your experiences, feelings, and opinions as to how people with HIV feel and how they are treated. Please tell me how much you agree or disagree with each statement. There are no right or wrong answers.
Have you ever told anyone (for example, family members, friends, or sex partners) that you have HIV?
Yes
No
*** SKIP INSTRUCTIONS: If the respondent answers “No”, please skip to Q7.
I have been hurt by how people reacted to learning I have HIV.
Strongly agree
Somewhat agree
Somewhat disagree
Strongly disagree
I have stopped socializing with some people because of their reactions to my having HIV.
Strongly agree
Somewhat agree
Somewhat disagree
Strongly disagree
I have lost friends by telling them I have HIV.
Strongly agree
Somewhat agree
Somewhat disagree
Strongly disagree
I am very careful who I tell that I have HIV.
Strongly agree
Somewhat agree
Somewhat disagree
Strongly disagree
I worry that people who know I have HIV will tell others.
Strongly agree
Somewhat agree
Somewhat disagree
Strongly disagree
I feel that I am not as good a person as others because I have HIV.
Strongly agree
Somewhat agree
Somewhat disagree
Strongly disagree
Having HIV makes me feel unclean.
Strongly agree
Somewhat agree
Somewhat disagree
Strongly disagree
Having HIV makes me feel that I’m a bad person.
Strongly agree
Somewhat agree
Somewhat disagree
Strongly disagree
Most people think that a person with HIV is disgusting.
Strongly agree
Somewhat agree
Somewhat disagree
Strongly disagree
Most people with HIV are rejected when others find out.
Strongly agree
Somewhat agree
Somewhat disagree
Strongly disagree
Taking ARV Meds
INTERVIEWER READ: Now I am going to ask you about HIV medications (antiretroviral medications).
1. Are you currently taking any HIV medications?
(These are medications such as [give a few common examples of HIV meds] and are NOT medications such as Bactrim or [another example])
Yes
No
*** SKIP INSTRUCTIONS: If the respondent answers “No”, please skip to the next section of the survey.
2. During the past 7 days, I took:
ALL my pills
MOST of my pills
About ONE-HALF of my pills
VERY FEW of my pills
NONE of my pills
3. When was the last time you missed any of your HIV medications?
Within the past week
1-2 weeks ago
2-4 weeks ago
1-3 months ago
More than 3 months ago
I never skip medications
Social Support (MOS Scale)
INTERVIEWER READ: People sometimes look to others for friendship, assistance, or other types of support. How often is each of the following kinds of support available to you if you need it?
1. How often do you have someone to turn to for suggestions about how to deal with a personal problem?
None of the time
A little of the time
Some of the time
Most of the time
All of the time
2. How often do you have someone to help with daily chores if you were sick?
None of the time
A little of the time
Some of the time
Most of the time
All of the time
3. How often do you have someone to love you and make you feel wanted?
None of the time
A little of the time
Some of the time
Most of the time
All of the time
4. How often do you have someone to do something enjoyable with?
None of the time
A little of the time
Some of the time
Most of the time
All of the time
Mental Health (BSI)
INTERVIEWER READ: The following is a list of problems and concerns that people sometimes have. Please indicate how you have been feeling during the past week, including today. Please choose one answer only.
1. In the past week, how much have you been bothered by nervousness or shakiness inside?
Not at all
A little bit
Moderately
Quite a bit
Extremely
2. In the past week, how much have you been bothered by feeling easily annoyed or irritated?
Not at all
A little bit
Moderately
Quite a bit
Extremely
3. In the past week, how much have you been bothered by thoughts of ending your life?
Not at all
A little bit
Moderately
Quite a bit
Extremely
4. In the past week, how much have you been bothered by being suddenly scared for no reason?
Not at all
A little bit
Moderately
Quite a bit
Extremely
5. In the past week, how much have you been bothered by temper outbursts that you could not control?
Not at all
A little bit
Moderately
Quite a bit
Extremely
6. In the past week, how much have you been bothered by feeling lonely?
Not at all
A little bit
Moderately
Quite a bit
Extremely
7. In the past week, how much have you been bothered by feeling blue?
Not at all
A little bit
Moderately
Quite a bit
Extremely
8. In the past week, how much have you been bothered by feeling no interest in things?
Not at all
A little bit
Moderately
Quite a bit
Extremely
9. In the past week, how much have you been bothered by feeling fearful?
Not at all
A little bit
Moderately
Quite a bit
Extremely
10. In the past week, how much have you been bothered by feeling easily hurt?
Not at all
A little bit
Moderately
Quite a bit
Extremely
11. In the past week, how much have you been bothered by feeling hopeless about the future?
Not at all
A little bit
Moderately
Quite a bit
Extremely
12. In the past week, how much have you been bothered by feeling tense or keyed up?
Not at all
A little bit
Moderately
Quite a bit
Extremely
13. In the past week, how much have you been bothered by having urges to beat, injure, or harm someone?
Not at all
A little bit
Moderately
Quite a bit
Extremely
14. In the past week, how much have you been bothered by having urges to break or smash things?
Not at all
A little bit
Moderately
Quite a bit
Extremely
15. In the past week, how much have you been bothered by having spells of terror or panic?
Not at all
A little bit
Moderately
Quite a bit
Extremely
16. In the past week, how much have you been bothered by getting into frequent arguments?
Not at all
A little bit
Moderately
Quite a bit
Extremely
17. In the past week, how much have you been bothered by feeling so restless you could not sit still?
Not at all
A little bit
Moderately
Quite a bit
Extremely
18. In the past week, how much have you been bothered by feeling worthless?
Not at all
A little bit
Moderately
Quite a bit
Extremely
Alcohol Use
INTERVIEWER READ: This portion of the questionnaire is about your use of alcoholic drinks during the PAST 90 DAYS. By a “drink”, I mean a can of beer, a glass of wine, or a shot of hard liquor.
1. In the past 90 days, how often did you have a drink containing alcohol?
Every day
4 or more times a week
2-3 times a week
2-4 times a month
Monthly or less
Never
***SKIP INSTRUCTIONS: If the respondent answers “Never”, please skip to Q5.
2. How many drinks containing alcohol do you have on a typical day when you drink?
1 or 2
3 or 4
5 or 6
7 or 8
9 or more
3. In the past 90 days, did you have 5 or more alcoholic drinks on one occasion?
Yes
No
***SKIP INSTRUCTIONS: If the respondent answers “No”, please skip to the next section of the survey.
4. How often do you have 5 or more alcoholic drinks on one occasion?
Daily or almost daily
Weekly
Monthly
Less than monthly
Never
***SKIP INSTRUCTIONS: After completing Q4, please skip to the next section of the survey.
5. You indicated that you did not have a drink containing alcohol in the past 90 days.
Did you become sober in the past 12 months?
Yes
No
Drug Use
INTERVIEWER READ: In this section, I am going to ask you some questions about drug use. The first question asks you to choose all answers that apply to you. Before proceeding with these questions, I would like to remind you that all your responses are confidential.
1. Which of the following drugs, if any, have you ever used? (Check all that apply)
____ Powder Cocaine (snort)
____ Crack Cocaine (rock, gravel)
____ Heroin (horse, smack, tar)
____ Crystal Methamphetamine (Crystal Meth, Ice, Tina, Glass)
____ Other Amphetamines (Speed)
____ Prescription drugs or painkillers without a prescription (Oxycontin, Codeine, Demerol, Darvon, Xanex)
____ None – you have never used any of these drugs
*** SKIP INSTRUCTIONS: For any of the above drug items that are checked, please skip to the corresponding item(s) below (Q2-Q7) about use in the past 90 days. Please ask only about those drugs that the respondent indicated EVER using. If the respondent answers “None” or “Don’t Want to Answer”, please skip to Q8.
2. You said that you have used powder cocaine (snort.) Have you used powder cocaine in the past 90 days?
Yes
No
3. You said that you have used crack cocaine (rock, gravel.) Have you used crack cocaine in the past 90 days?
Yes
No
4. You said that you have used heroin (horse, smack, tar). Have you used heroin in the past 90 days?
Yes
No
5. You said that you have used Crystal Methamphetamine (Crystal Meth, Tina). Have you used Crystal Methamphetamine in the past 90 days?
Yes
No
6. You said that you have used amphetamines (speed). Have you used amphetamines in the past 90 days?
Yes
No
7. You said that you have used prescription drugs or painkillers without a prescription (Oxycontin, Codeine, Demerol, Darvon). Have you used prescription drugs or painkillers without a prescription in the past 90 days?
Yes
No
8. Have you ever injected any non-prescription drugs (such as cocaine or heroin)?
Yes
No
*** SKIP INSTRUCTIONS: If the respondent answers “No” or “Don’t Want to Answer”, please skip to Q10.
9. Have you injected any non-prescription drugs in the past 90 days?
Yes
No
10. In the past 12 months were you in any alcohol or drug treatment program, such as inpatient or outpatient treatment, or detox?
Yes
No
11. In the past 12 months have you participated in any alcohol or drug self-help program, such as AA, NA or 12-step? (Only include a program for you, not for someone else, such as Al-Anon).
Yes
No
Unmet Needs
INTERVIEWER READ: In this section I am going to read you a list of services. For each service, please tell me if you felt like you needed this service during the past 6 months. For those services that you tell me you needed, I will then ask you if you got that service.
*** SKIP INSTRUCTIONS: For each service (1 - 8) below, first ask the question in Column A (“Did you need . . .”). If the respondent answers “Yes”, then ask the question in Column B (“Were you able to get . . .”). If the respondent answers “No” to a service in Column A, then skip to the next service below and repeat the question in Column A.
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A. Did you need [Interviewer: insert service] during the past 6 months? |
B. Were you able to get [Interviewer: insert service] during the past 6 months? |
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Yes (Go to the box to the right) No (Skip to the box below) |
Yes Sometimes No
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Yes (Go to the box to the right) No (Skip to the box below)
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Yes Sometimes No
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Yes (Go to the box to the right) No (Skip to the box below)
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Yes Sometimes No
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Yes (Go to the box to the right) No (Skip to the box below)
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Yes Sometimes No
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Yes (Go to the box to the right) No (Skip to the box below)
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Yes Sometimes No
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Yes (Go to the box to the right) No (Skip to the box below)
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Yes Sometimes No
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Yes (Go to the box to the right) No (Skip to the box below) |
Yes Sometimes No
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Yes (Go to the box to the right) No |
Yes Sometimes No |
Incarceration
INTERVIEWER READ: These next few questions are about incarceration. By incarceration, we mean being locked up in jail or prison.
In the past six months, have you been in jail or prison?
Yes
No
*** SKIP INSTRUCTIONS: If the respondent answers “No” or “Don’t Want to Answer”, please skip to Q3.
How much total time have you spent in jail or prison in the past six months?
1 day
Between 2 and 7 days
Between 8 and 30 days
More than 30 days
Are you currently on probation or parole?
Yes
No
Structural and Financial Barriers
INTERVIEWER READ: Now I am going to ask you some questions about things that may have made it difficult for you to get HIV medical care. Please tell me if any of the following problems made it difficult for you to get HIV medical care in the PAST 6 MONTHS.
1. In the past 6 months, were you worried about how you would pay for your HIV medical care (for example, you didn’t have insurance, your insurance would not pay, you were worried about spending your own money for co-pays and for prescriptions)?
Yes
No
2. In the past 6 months, did you have problems making an appointment for HIV medical care because you did not have a telephone?
Yes
No
3. In the past 6 months, did you have problems getting someone to answer your calls to get a health care appointment?
Yes
No
4. In the past 6 months, did you have trouble getting an appointment at a time that was good for you?
Yes
No
5. In the past 6 months, did you have a problem finding providers who speak your language?
Yes
No
6. In the past 6 months, did you have problems getting transportation to the clinic for your appointment?
Yes
No
History of HIV
INTERVIEWER READ: Now I am going to ask you a few questions about when you first tested HIV-positive and the medical care you get for your HIV.
2. After you first tested HIV-positive in [insert date above], how long was it before you went to an HIV health care provider for the very first time? (By HIV health care provider, we mean a doctor, physician’s assistant, or nurse practitioner who treats you for your HIV)
Less than 3 months
3 - 6 months
More than 6 months but less than 12 months
Longer than 12 months
3. Since you first tested HIV-positive, what was the longest period you went without seeing an HIV health care provider?
Less than 6 months
Between 6 and 12 months
More than 12 months
Engagement with Provider
INTERVIEWER READ: The next few questions are about interactions between you and your main HIV health care provider during your most recent visit to this clinic. By “main HIV health care provider”, we mean a doctor, physician’s assistant, or nurse practitioner who treats you for your HIV. Please tell me how much you agree or disagree with each statement about your main HIV health care provider.
1. During my most recent visit at this clinic, my main HIV health care provider listened carefully to me.
Strongly agree
Somewhat agree
Somewhat disagree
Strongly disagree
2. During my most recent visit at this clinic, my main HIV health care provider explained things in a way that I could understand.
Strongly agree
Somewhat agree
Somewhat disagree
Strongly disagree
3. During my most recent visit at this clinic, my main HIV health care provider showed respect for what I had to say.
Strongly agree
Somewhat agree
Somewhat disagree
Strongly disagree
4. During my most recent visit at this clinic, my main HIV health care provider spent enough time with me.
Strongly agree
Somewhat agree
Somewhat disagree
Strongly disagree
| File Type | application/msword |
| File Title | TAB 1 |
| Author | Faye Malitz |
| Last Modified By | HRSA |
| File Modified | 2009-07-16 |
| File Created | 2009-06-30 |