Survey: Reproductive Health in Young Women with Type 1 Diabetes

Participant Full Name

General information about you:

Address

*Mobile:

*Postcode

*Phone

*Email:

Consent Form completed – Date

*1. Date of birth

*2. Country of birth

2b. If Australia is not your country of birth how many years have you been in Australia?

2c. Are you of Aboriginal origin?

Yes

No

2d. Are you of Torres Strait Islander origin?

Yes

No

2e. In which country was your mother born?

2f. In which country was your father born?

*3. What is your postcode?

4a. What is the highest level of schooling you have completed?

4b. What is the highest post-school qualification you have completed?

4c. Are you a student?

4d. Do you currently work -

4e. What is your main occupation NOW?

Select one only

4f. Do you receive a pension/health care card?

Yes – please go to question 4g

No

Don’t know

4g. What type of pension do you receive?

5a. At present are you…

5b. At present are you…

5c. Do you…

*6. What is the date of diagnosis of your diabetes?

The following question relate to your diabetes and general health.

7. Do you have any other medical or surgical conditions? (eg. Asthma)

Yes

No

If yes – please specify

8. How often do you monitor your blood glucose levels?

9. How many injections of insulin do you take per day?

10a. Have you had your HbA1c checked?

Yes

Don’t know

Never had HbA1c checked

If yes, when was it last tested?

10b. What do you think is your target HbA1C

10c. Over the last 2 years, has your HbA1C been:

10d. Do you remember your most recent level, if so please enter below.

Yes

No

If yes, the level was

10e. If you have not had your HbA1c checked within the last 12 months, what were the reasons?

Please specify

11. How often do you attend specialist appointments for your diabetes?

12. Do you have any complications associated with your diabetes?

Other - please specify

13. Do you take any regular medications other than insulin?

Please specify

14. Which of these do you think are some of the problems/fears about your future health? (Select all that you feel apply)

Please specify

15a. What would you expect to be the most helpful source(s) of information on your general health? (Select all that you feel apply)

Please specify

15b. If you selected anything from the above list, which source has been the most helpful?

Please tick one box for each question.

16a. Do you smoke?

Yes

No

Think back over the last TWO WEEKS… 16b. How many cigarettes do you usually smoke per day?

16c. How many years and/or months have you been smoking?

17a. How often do you have an alcoholic drink?

17b. On a day that you have an alcoholic drink, how many standard drinks do you usually have? (a standard drink is a small glass of wine or glass of beer; a nip of spirits or a mixed drink)

Think back over the last TWO WEEKS for questions 17c and 17d 17c. How many times have you had three or more alcoholic drinks on any one occasion?

17d. How many times have you had five or more alcoholic drinks on any one occasion?

17e. How many times, if ever, have you smoked or used marijuana/cannabis?

17f. Have you ever injected drugs (e.g. speed, steroids, heroin NOT prescribed by your doctor)?

Yes

No

17g. During the past 12 months, have you injected drugs NOT prescribed by your doctor?

Yes

No

The following questions relate to reproductive health

18a. Have you ever had a menstrual period?

Yes

No

If no, Please go to question 19a

18b. How old were you when your periods commenced?

18c. Did your periods commence naturally or was hormone treatment necessary?

Naturally

Hormone-treatment required

18d. Since your periods first started, what has been the longest time between periods (in months)?

18e. Did your periods re-start naturally or with hormone replacement therapy (the pill)?

18f. Do you currently have regular periods?

18g. If you have regular periods, how long is your usual cycle (the number of weeks between the start of one period and the start of the next period)?

18h. If you have irregular periods, could you please describe them briefly?

18i. How many days does your period usually last?

18j. What do you consider your menstrual flow to be like?

18k. Have your periods been complicated by spotting (occasional bleeding or spotting of blood at a time when you aren’t due for your period)?

18l. Are your periods complicated by flooding or clots (very heavy bleeding)?

18m. Do you have painful periods (such that you take pain killing tablets or take time off work/study/activity)?

19a. Are you currently taking hormone replacement therapy (oestrogen) or the oral contraceptive pill?

Yes

No

Briefly explain reasons for above response

Please go to Question 19c

19b. Who prescribes the pill for you?

19c. Have you received birth control education / advice from YADS clinic?

Yes

No Please go to question 20a

19d. Did you find that the education / advice was helpful?

Yes

No

If NO please state reason

20a. Have you ever had a PAP smear (cervical smear test)?

Yes

No

please go to question 20c

20b. Have you had a PAP smear (cervical smear test) in the past 2 years?

Yes

No

20c. Have you had the cervical cancer vaccine (injection)?

Yes

No

21. Have you ever had a urinary tract infection diagnosed?

Yes

No

22. How much do you worry that you could catch a sexually transmitted infection?

23a. Do you have issues with excessive facial hair?

Yes

No

23b. Do you have issues with acne?

Yes

No

23c. Do you have issues with being overweight?

Yes

No

23d. What is your weight in kgs?

23e. What is your height?

23f. Given the opportunity, would you like to talk to a gynaecologist (women’s health specialist) about any of the above items?

Yes

No

Briefly explain the reason for your above response

The following questions are about sexual activity.

24a. Have you ever had sexual intercourse?

Yes

No - please go to question 24d

24b. Was the last person you had sex with…

Male

Female

24c. How old were you when you first had sexual intercourse?

Yes

No - please go to question 24k

24e. If you do currently use a form of contraception (birth control) is it mainly for

Other – please state

24f. What contraceptive method do you use usually?

Other – please specify

24g. What do you consider to be the most effective form of contraception (birth control)?

Other – please specify

24h. How much of a problem for you is the cost of birth control?

24i. How much of a problem for you is getting birth control?

24j. How much of a problem for you is using birth control on a regular basis?

24k. Has a health care professional (doctor, nurse, etc) told you that you should use some type of birth control to prevent an unplanned pregnancy?

Yes

No

24l. Has anyone else (boyfriend, parent, friend, etc) told you that you should use some type of birth control to prevent an unplanned pregnancy?

Yes

No

24m. Do you believe using birth control will prevent an unplanned pregnancy?

24n. Do you think your using birth control is (will be):

24o. Do you think your using birth control is (will be):

24p. Would you say that your boyfriend/partner/husband thinks you should use birth control to prevent an unplanned pregnancy?

24q. When it comes to using birth control, do you want to do what your boyfriend/partner/husband thinks you should do?

24r.Would you say that your parents think you should use birth control when preventing a pregnancy?

24s. When it comes to using birth control, do you want to do what your parents think you should do?

24t. Would you say that most of your friends think that you should use birth control when preventing a pregnancy?

24u. When it comes to using birth control, do you want to do what most of your friends think you should do?

24v. When you have sex, do you always intend to use some type of birth control to prevent an unplanned pregnancy?

24w. When you have sex, do you intend to use a birth control method that gives you full protection against unplanned pregnancy?

The following questions relate to pre-pregnancy counselling.

25a. Do you believe that you can become pregnant?

25b. Have you ever tried to become pregnant?

Yes

No

25c. How much do you worry that you could become pregnant?

25d. How much do you worry that you could develop health problems during pregnancy?

25e. How much do you worry that your baby could help develop health problems during your pregnancy?

25f. If you developed health problems during your pregnancy, do you think that those problems would be:

25g. If your baby developed health problems during your pregnancy, do you think that the problems would be:

26. Are you considering becoming pregnant in the next 12 months?

Yes

No

27a. Have you ever been pregnant?

Yes

No - please go to question 31a.

27b. Were any of your pregnancies conceived naturally?

Yes

No

If yes – please state how many?

27c. Did you require any form of intervention/medical assistance (including “IVF”) required for any of the pregnancies?

Yes

No

If yes, please specify

28. Were any of your pregnancies unplanned?

29a. If Yes, what form of contraception were you using at the time?

If other - please specify

29b. If you had an unplanned pregnancy, do you think that this problem would be:

30. Have you ever had a spontaneous (naturally occurring) miscarriage?

Yes

No

31a. Have you ever had a termination (medical or surgically induced) of pregnancy?

Yes

No - please go to question 31a

31b. Reason for termination?

If other please specify

32a. Have you received any pre-pregnancy counselling or advice from YADS or Diabetes clinic here at Monash Medical Centre?

Yes

No

32b. If you answered YES, did you find the advice helpful?

Yes

No

If no, please state reasons advice not helpful

33a. Would having blood glucose levels in the normal range before becoming pregnant improve your chances of having a healthy baby?

33b. Would seeking pre-pregnancy counselling (special medical care and advice) when planning a pregnancy improve your chances of having a healthy baby?

33c. Would getting pre-pregnancy counselling (special medical care and advice) improve your chances of having a healthy pregnancy?

33d. How much of a problem would it be to seek pre-pregnancy counselling (special medical care and advice) when planning a pregnancy?

33e. How much of a problem would it be to follow the pre-pregnancy counselling advice given by health professionals (eg keeping blood glucose levels in the normal range, taking more insulin injections, etc)?

33f. Have you ever discussed how diabetes affects pregnancy with your regular diabetes health care provider?

Yes

No

33g. Has a health care professional (doctor, nurse, etc) ever told you that you should get special medical care and advice before you become pregnant or plan for a pregnancy?

Yes

No

33h. Has anyone else (boyfriend, parent, friend, etc) told you that you should get pre-pregnancy counselling (special medical care and advice) before you become pregnant or plan for a pregnancy?

Yes

No

33i. For you to get pre-pregnancy counselling (special medical care and advice) when planning pregnancy is (will be):

33j. Would you say that your boyfriend/partner/husband thinks you should seek pre-pregnancy counselling (special medical care and advice) when planning a pregnancy?

33k. When it comes to pre-pregnancy counselling do you want to do what your boyfriend/partner/husband thinks you should do?

33l. Would you say that your parents think you should seek pre-pregnancy counselling (special medical care and advice) when planning a pregnancy?

33m. When it comes to pre-pregnancy counselling do you want to do what your parents think you should do?

33n. Would you say that most of your friends think you should seek pre-pregnancy counselling (special medical care and advice) when planning a pregnancy?

33o. When it comes to pre-pregnancy counselling do you want to do what most of your friends think you should do?

For the following questions, on a scale of 0 to 10, rate how confident you are, that you could regularly do each activity for at least 6 months. Choose the number from 0 to 10 that best describes your level of confidence, where 0 is not at all confident

How confident am I that I could:

34. Get pre-pregnancy counselling before I get pregnant.

35. Convince my boyfriend/partner/husband that it is necessary for me to use birth control, even if he does not want me to use it.

36. Change my insulin and diet to keep my blood glucose levels in normal range, even if I am not yet pregnant, but planning a pregnancy.

37. Delay sex with my boyfriend/partner/husband if birth control is not available.

38. Wait on becoming pregnant until my blood glucose levels are within the normal range.

39. Use birth control each time I have sex when preventing a pregnancy.

For the following questions, would you say that getting pre-pregnancy counselling

40. Would help you get normal blood glucose

41. Would help you understand how diabetes affects pregnancy

42. Would help you decide what birth control method to use

43. Would you say that using birth control would help you prevent an unplanned pregnancy

Thank you! You have completed the questionnaire!

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Survey: Reproductive Health in Young Women with Type 1 Diabetes