Instructions: Module 4B - TheMeasurementGroup.com

SPNS COOPERATIVE AGREEMENT EVALUATION

MODULE 4B: BARRIERS AND FACILITATORS FORM INSTRUCTIONS

Citation: Huba, G. J., Melchior, L. A., Staff of The Measurement Group, and HRSA/HAB's SPNS Cooperative Agreement Steering Committee (1997). Module 4B: Barriers and Facilitators Form. Available: www.TheMeasurementGroup.com. Culver City, California: The Measurement Group.

This form is intended to be used in the interview format. It is not intended for the client to fill out by himself or herself.

Answer questions by either filling in a circle, or writing a number or letter in a square box. If the answer goes in a square box, you must use a CAPITAL LETTER or number that does not touch the side of the box. Print only one letter or number in each box. If the letters or numbers that you print touch the sides of the boxes, or if you do not clearly print the information, the computer will "kick out" the form and we will need to return it to you to be completed correctly. If the question asks the answer to be filled in a circle, make sure that the circle is completely darkened. Only darken one circle for each question unless the instructions specifically tell you to darken as many as apply for that question.

Specific Parts of the Module 4B: Barriers and Facilitators Form

ID Letters/ID Numbers. These boxes are provided for entering the unique identifier your site is using to track client information. The four boxes on the left are to be used for letters, while the ten boxes on the right are reserved for numbers. You may use letters, numbers, or a combination of letters and numbers, for identification purposes. If you use a combination of letters and numbers, however, please use the letters first in your alphanumeric sequence (for example, if your unique identifier is MD-1479, the letters "M" and "D" would be entered in the first two of the four boxes reserved for letters and the numbers "1", "4", "7", and "9" would be entered into the first four of the ten boxes reserved for numbers). If you are unsure about the unique identifier for this client, check with your project director.

Site. This is a code to identify your project in the cross-cutting evaluation. It should be pre-printed on the form. If it has not been already entered on the form, check in the table below. Site codes are 3 letters.

Site Code	ORGANIZATION
AHF	AIDS Healthcare Foundation
DCW	Center for Women Policy Studies
CCY	Cook County Hospital
EBO	East Boston Neighborhood Health Center
EMY	Emory University
HAI	Haitian Community AIDS Outreach Project
HFY	Health Initiatives for Youth
IND	Indiana Community AIDS Action Network
IAC	Interamerican College of Physicians and Surgeons
HOP	Johns Hopkins University
LAR	Larkin Youth Center
VER	Medical Center Hospital of Vermont
MIC	Michigan Protection and Advocacy
MDH	Missouri Department of Health
COL	Mountain-Plains AETC
NYS	New York State Dept. of Health
OTR	OUTREACH, Inc.
PRO	PROTOTYPES
SNY	Research Foundation of SUNY
FOR	The Fortune Society
MSP	University of Mississippi Medical Center
REN	University of Nevada School of Medicine
WAS	University of Washington Center for AIDS and STD
TEX	University of Texas Health Science Center
VNA	Visiting Nurse Association of LA
STL	Washington University School of Medicine
WBI	Well-Being Institute

Sub-Provider. This field may be used to designate specific sites or providers within your project. If appropriate, enter the code of the service provider agency doing the activity. Provider codes can be up to three letters.

Date. Enter the numbers representing today's date (the date of the activity) in these boxes. Enter the month as a number from 01 to 12 for January through December. Enter the day as a two-digit number (01 to 31). Enter the last two digits of the current year (for example, "96" for 1996). Make sure that if a month or day is less than 10, you place a "0" before the number.

Staff Code. Each staff member should be assigned a unique number code (up to 3 digits). Make sure that each new staff member has a unique code. Do not reassign any staff codes that have been previously assigned. Enter the 3-digit code for the person who provided the services. If the staff code is less than 3 digits, place "0"s before the number. For example, 3 is 003.

Section 1. READ TO RESPONDENT: "Sometimes people have problems getting services. I am going to read you a list of problems people report. For each statement, please tell me if it is a problem for you. Is this a problem for you?"

For questions 1 through 17 in Section 1, read each statement to the respondent and record his/her response by darkening the appropriate circle on Module 4B. If necessary, see explanations of statements listed below. If the respondent says that the statement is true or that it is a problem for him/her, darken the circle to the left of "Yes." If the respondent says that the statement is false or that it is not a problem for him/her, darken the circle to the left of "No." If the respondent does not know, darken the circle, next to "D/K." Darken the circle to the left of "Ref." if the respondent refuses to answer. For item 8, "You don’t know what to do with your kids when you’re there," and item 11, "You are afraid that you might lose your child if you go there," darken the circle to the left of "N/A" if the respondent does not have children.

Statements	Definition
You don’t think the services exist around here.	The respondent believes that the services he or she needs are not available in the catchment area. It might be that the respondent thinks that the type of service is not offered at all, or that the service is available, but not nearby.
You don’t know where to get the services.	The respondent is not sure where to go to get these services. It may be related to not knowing the services exist in the first place, or it may be a case of knowing the services exist but not knowing where specific service providers are located.
You would have to wait too long to get the services.	The respondent believes that he/she would wait for a long time to receive services. The wait is perceived to be so long that it makes it difficult to get the services, or so much of a hassle that the respondent may decide it is not worth the wait.
The services cost too much for you to afford.	The respondent believes that he/she cannot afford to pay for services at this agency. Although some agencies may in fact be relatively affordable, this question asks whether the respondent perceives the services to be too expensive for him or her to be able to pay.
You don’t think you are eligible to get the services for free.	The respondent believes that he/she is not eligible to receive free services. This may be because the respondent’s thinks his/her income level is not consistent with the criteria for free services, or because he or she may believe that free services are not available at all.
The people who run the services don’t like people like you.	The respondent believes or fears that he/she would be discriminated against by service providers. The discrimination could be for any reason – due to a person’s ethnicity, cultural group, HIV status, gender, substance abuse history, mental illness history, etc. The key is that the individual feels that he or she would not "fit in" at the agency.
It’s hard for you to get there (transportation).	The respondent finds it difficult to get to the agency due to lack of transportation. This may be because of a lack of access to a car, not living near public transportation, not being able to afford transportation, etc.
You don’t know what to do with your kids when you’re there.	The respondent does not get the services because he/she does not have anyone to watch his/her children while he/she obtains services. This could be formal child care offered at the agency or nearby, or having a relative or friend take care of the child(ren).
Somebody might find out about your HIV status if you go there.	The respondent is reluctant to be seen in the facility because someone might find out his/her HIV status. It could be someone affiliated with the agency, or someone not affiliated with the agency who might see the respondent going to the service provider’s office, or it might be a fear of information being shared among service providers.
You are afraid that you won’t be treated if you go there.	The respondent fears that he/she might be refused treatment at the agency.
You are afraid that you might lose your child if you go there.	The respondent fears that as his/her child(ren) might be taken away by child protective services as a result of using services.
You worry that someone there will force you to take medication.	The respondent fears that agency staff may persuade or force him/her to take medicine that she/he does not want to take. This may affect both medical providers who directly prescribe medication, as well as non-medical providers who may be doing medical case management with the respondent.
It’s hard for you to make or keep appointments.	It is difficult for the respondent to show up for appointments or to schedule appointments. This might be in general, or with respect to a specific agency.
The people at the agency don’t speak the same language as you.	There is a language barrier between the respondent and agency staff, making it difficult to receive services there.
You have trouble telling the people at the agency what you need.	The respondent has difficulty communicating his/her needs to agency staff.
You worry that you family/friends would be against the services.	The respondent feels that the people close to him/her would object to him/her receiving these services.
You have to take care of other people.	The respondent is responsible for the care of dependent individuals and cannot easily attend appointments, or feels that his/her needs are secondary to those of others (e.g. family, friends).

Section 2. READ TO RESPONDENT: "Sometimes there are things that make it easier to get services. I am going to read you a list of things that make it easier for people to get services. For each statement, please tell me if it has helped you get services or made getting services easier. Has this helped you?"

For questions 1 through 11 in Section 2, read each statement to the respondent and darken the circle next to his or her response. If the respondent says that the statement is true or that it does make getting services easier, darken the circle to the left of "Yes." If the respondent says that the statement is false or that it does not make getting services easier, darken the circle to the left of "No." If the respondent does not know, darken the circle, next to "D/K." Darken the circle to the left of "Ref." if the respondent refuses to answer. For item 4, "Child care is provided to you by the agency," darken the circle to the left of "N/A" if the respondent does not have children.

Statements	Definition
People at the agency seem to care about you.	The respondent believes that agency staff have positive feelings about him/her.
Food is provided for you at the agency.	The respondent is given food when he/she receives services at the agency.
You get other items or goods when you are seen at the agency.	Items or goods are given to the respondent as incentives to participate in studies, or as part of the program's services. This could include a necessities canteen where sundries are available for clients, or vouchers are provided to get these items for low- or no-cost elsewhere.
Child care is provided to you by the agency.	The respondent has children who are taken care of by the agency when he/she is there receiving services. The child care could be provided at the agency, or the agency may provide arrangements for child care that is located elsewhere.
The agency is located near where you live.	The respondent lives near the agency which allows him/her to easily access services.
You learn important things at the agency.	The respondent believes that he/she receives important information from the agency.
Transportation is provided to bring you to the agency.	The respondent is transported by an agency vehicle (van, bus, car, etc.) or is given transportation vouchers, passes, or tokens.
It is easy to talk to the people at the agency.	The respondent feels comfortable expressing his/her thoughts to agency staff.
The agency offers you appointments that are at convenient times.	The respondent believes that the scheduled appointments are convenient for him/her to keep.
You meet people that you like at the agency.	The respondent likes staff and other clients/ patients at the agency.
Safe parking is located at the agency.	The respondent is able to park safely at or near the agency.

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