Default Question Block

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1 1 of 8 5/2/2013 3:57 PM Default Question Block Thank you for agreeing to complete this anonymous survey about your gynecological and reproductive health. "Anonymous' means that no information that would identify you is collected from this survey. You may skip any question you do not want to answer. You must be 18 years old to answer these questions. Answering the questions will take approximately 5 to 10 minutes. For this survey, GYNECOLOGICAL and REPRODUCTIVE health refers to things like managing your periods, contraception, sexuality and sexual functioning, pregnancy planning, pelvic pain, preventative care (e.g., mammograms and pap smears) and menopause. The purpose of this survey is to learn about your priorities for this part of your health as a woman with a disability. We are also interested in your gynecological and reproductive health experiences and barriers you have faced to getting the care you need. Please feel free to share the web link to this survey you received for the survey with your female friends and colleagues who have a disability. We want to hear from as many women as possible! If you would like to learn more about this research or tell us more about your experiences and point of view, please feel free to the researcher, Dr. Claire Kalpakjian, at clairez@umich.edu. THANK YOU! First, tell us a little about yourself. 1. How old are you? 2. What is your racial/ethnic background? (Check all that apply) White/Caucasian African American Hispanic Asian Native American Pacific Islander Describe "other".

2 2 of 8 5/2/2013 3:57 PM 3. Select which category or categories that best describe(s) your disability. (Check all that apply) Physical disability (such as, spinal cord injury, spina bifida) Cognitive disability (such as, traumatic brain injury, stroke) Sensory disability (such as, vision or hearing impairment) Psychiatric disability (such as, depression, anxiety, substance abuse) Intellectual disability (such as, learning disability) 4. Briefly, tell us about your disability. 5. Do you use a wheelchair and/or other devices for mobility? Yes No What types of devices do you use? Briefly describe your level of mobility. For example, can walk without a problem, can walk with a device, or can't walk at all. The next set of questions asks about your gynecological and reproductive NEEDS and if you are getting the care you need.

3 3 of 8 5/2/2013 3:57 PM 6. What kind of health care provider(s) do you see for your gynecological and reproductive health care needs? (Check all that apply) Gynecologist Family practice physician Internist Rehabilitation physician (physiatrist) Nurse practioner Describe "other". 7. What are your gynecological and reproductive health care needs? 8. Are your gynecological and reproductive health care needs being met? Yes Only somewhat No Describe how your needs are not or are only somewhat being met. 9. Do you think your disability affects your gynecological and reproductive health needs? Yes Somewhat No In what ways do you think your disability affects your gynecological and reproductive health?

4 4 of 8 5/2/2013 3:57 PM The next set of questions is about BARRIERS you may have experienced when getting the gynecological and reproductive health care you need. 10. Have you experienced barriers of any kind in getting the gynecological and reproductive health care you need? Yes Somewhat No What kinds of barriers have you experienced? Check all that apply. Attitudinal barriers (these are negative attitudes of health care providers or systems you believe have a negative attitude towards you as a woman with a disability) Structural barriers (these are in the built environment, like not being able to access equipment, exam tables or doctor's offices) Knowledge barriers (these are related to you or your health care providers not having enough information or the right kind of information to make the best decisions about your gynecological and reproductive health) Resource barriers (these are related to having the right health care resources in your community and being able to get to them) Insurance barriers (these are related to not having enough or the right insurance you need) With whom have you experienced ATTITUDINAL barriers? (Check all that apply) Physician Nurse or nursing assistant staff (e.g., receptionist, medical assistants) If other, briefly describe Briefly describe what experiencing the attitudinal barrier(s) was like and how it made you feel.

5 5 of 8 5/2/2013 3:57 PM What sorts of STRUCTURAL barriers have you experienced? What kind of INFORMATION OR KNOWLEDGE should you or your health care providers have, but do not? What kinds of RESOURCE barriers have you experienced? 11. Are there OTHER barriers that you have encountered or that you have heard about that SHOULD be listed, but aren't? This next set of questions asks about how you PRIORITIZE your gynecological and reproductive health needs at this time in your life. 12. First, rank order the list below from MOST to LEAST important right now. In the box to the left of each choice, put a number, ranging from "1" as MOST important to "7" as LEAST important. Managing periods Sexuality and sexual functioning Contraception

6 6 of 8 5/2/2013 3:57 PM Pregnancy planning Pelvic pain Preventative care (e.g., mammograms or pap smears) Menopause 13. Next, rank order the same list from EASIEST to HARDEST in terms of getting the care you need. In the box to the left of each choice, put a number, ranging from "1" as EASIEST to "7" as HARDEST. Managing periods Sexuality and sexual functioning Contraception Pregnancy planning Pelvic pain Preventative care (e.g., mammograms or pap smears) Menopause 14. Finally, if you could tell the government, like the National Institutes of Health, what YOU think should be the priorities for funding research about gynecological and reproductive health in women with disabilities, which areas would be in YOUR top 3? In the box to the left of each choice, put a 1, 2 and 3 for your top three choices. Managing periods Sexuality and sexual functioning Contraception Pregnancy planning Pelvic pain Preventative care (e.g., mammograms or pap smears) Menopause Are there OTHER priorities you think are important that are NOT on the list above? What are the most important things that YOU think that clinicians and researchers should know about the gynecological and reproductive health of women with disabilities? This can be anything we did not ask about or more about something we did ask.

7 7 of 8 5/2/2013 3:57 PM Just a few more questions about you. You may skip any questions you do not wish to answer. 15. What kind of community do you live in? Urban (a big city) Suburban (near a big city) Rural (out in the country, a small town) 16. What is the highest level of education you have completed? Less than High School High School / GED Some College 2-year College Degree 4-year College Degree Masters Degree Doctoral Degree Professional Degree (JD, MD) 17. What is your annual income range? Below $20,000 $20,000 - $29,999 $30,000 - $39,999 $40,000 - $49,999 $50,000 - $59,999 $60,000 - $69,999 $70,000 - $79,999 $80,000 - $89,999 $90,000 or more

8 8 of 8 5/2/2013 3:57 PM 18. What kind of health insurance do you have? Check all that apply. SSDI Private Medicare 19. What is your employment status? Employed full-time Employed part-time Not employed 20. How would you describe your sexual orientation? Prefer men Prefer women Prefer both men and women I am not sure Prefer not to answer Thank you! If you would like to learn more about this research or share more of your experiences, please feel free to the researcher, Dr. Claire Kalpakjian, at clairez@umich.edu.