White/Caucasian African American Hispanic Asian Native American Pacific Islander Other
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 email 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)
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)
Other
Yes No
3. Select which category or categories that best describe(s) your disability. (Check all that apply)
4. Briefly, tell us about your disability.
5. Do you use a wheelchair and/or other devices for mobility?
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.
Gynecologist
Family practice physician Internist
Rehabilitation physician (physiatrist) Nurse practioner Other Yes Only somewhat No Yes Somewhat No
6. What kind of health care provider(s) do you see for your gynecological and reproductive health care needs? (Check all that apply)
Describe "other".
7. What are your gynecological and reproductive health care needs?
8. Are your gynecological and reproductive health care needs being met?
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
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)
Physician
Nurse or nursing assistant
Other staff (e.g., receptionist, medical assistants) Other
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?
What kinds of barriers have you experienced? Check all that apply.
With whom have you experienced ATTITUDINAL barriers? (Check all that apply)
If other, briefly describe
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
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.
Urban (a big city)
Suburban (near a big city)
Rural (out in the country, a small town)
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) 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
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?
16. What is the highest level of education you have completed?
SSDI Private Medicare Other Employed full-time Employed part-time Not employed Prefer men Prefer women
Prefer both men and women I am not sure
Prefer not to answer
18. What kind of health insurance do you have? Check all that apply.
19. What is your employment status?
20. How would you describe your sexual orientation?
Thank you!
If you would like to learn more about this research or share more of your experiences, please feel free to email the researcher, Dr. Claire Kalpakjian, at clairez@umich.edu.
